UNIVERSITY  OF  CAUFORNIA 

CALIFORNIA  COLLEGE  OF  MEDIC1N1 

LIBRARY 

JUN151970 

IRVINE,  CALIFORNIA  92664 


LABORATORY   METHODS 


LABORATORY  METHODS 


WITH  SPECIAL  REFERENCE  TO  THE  NEEDS  OF 


THE  GENERAL  PRACTITIONER 


BY 

r°H 

B.  G.  R.  WILLIAMS,  M.  D. 

MEMBER  OF  ILLINOIS  STATE  MEDICAL  SOCIETY.  AMERICAN  MEDICAL  ASSOCIATION,  ETC. 


ASSISTED  BY 


E.  G.  C.  WILLIAMS,  M.  D. 

FORMERLY  PATHOLOGIST  OF  NORTHERN  MICHIGAN  HOSPITAL  FOR  THE  INSANE, 
TRAVERSE   CITY,   MICHIGAN 


WITH  AN  INTRODUCTION  BY 

VICTOR  C.  VAUGHAN,  M.  D.,  LL.  D. 

PROFESSOR  OF  HYGIENE  AND  PHYSIOLOGICAL  CHEMISTRY  AND  DEAN  OF  THE  DEPARTMENT 
OF  MEDICINE  AND  SURGERY,   UNIVERSITY  OF  MICHIGAN,  ANN  ARBOR,  MICHIGAN 


SECOND  EDITION 


ILLUSTRATED  WITH  FORTY-THREE  ENGRAVINGS 


ST.   LOUIS 

C.  V.  MOSBY  COMPANY 
1913 


COPYRIGHT,  1913,  BY  C.  V.  MOSBY  COMPANY 


Press  of 

C.  V.  Mosby  Company 
St.  Louis 


TO 

THE  GENERAL  PRACTITIONER, 

WHO  MUST  BE  A  SPECIALIST  IN  ALL  BRANCHES  OP  MEDICINE, 

THIS  BOOK  IS  DEDICATED 

BY  THE  AUTHORS. 


PREFATORY  NOTE 

A  realization  of  the  fact  that  the  general  practitioner  is  not 
usually  prepared  to  make,  on  account  of  lack  of  extensive  apparatus 
and  other  conveniences,  elaborate  chemical  tests  and  examinations, 
has  prompted  the  authors  to  prepare  this  book.  "Laboratory 
Methods ' '  is  not  of  an  encyclopedic  form,  nor  is  it  a  limited  com- 
pend,  and  is  especially  designed  for  the  general  practitioner  who 
desires  to  make,  easily  and  inexpensively,  examinations  on  which 
he  may  depend. 

The  physician  may  have  experienced  some  discouragement  in 
attempts  to  conduct  certain  examinations,  but  he  has  probably 
been  confused  by  the  complexity  of  the  large  book  and  thwarted 
by  the  paucity  of  the  compend.  It  is  not  presumed  that  the  prac- 
titioner shall  attempt  every  investigation,  but  this  book  will  show 
that  many  .of  the  comparatively  simple  cases  that  are  usually  sent 
to  distant  cities  for  expert  examination  may  be  made  with  more 
satisfactory  results  by  the  practitioner. 

It  has  been  the  aim  of  the  authors  to  simplify  methods  both  as 
to  apparatus  and  technic.  Essential  factors  have  not,  however, 
been  omitted,  but  have  been  emphasized  in  such  manner  as  to  indi- 
cate their  importance.  Only  the  best  tests  are  given,  so  that  the 
reader  will  not  be  perplexed  by  being  obliged  to  do  any  choosing 
for  specific  cases.  Stress  has  been  laid  on  safe  diagnosis,  and 
sources  of  error,  as  well  as  the  value  and  limitation  of  tests,  have 
been  pointed  out. 

B.  G.  R.  W.,  M.  D. 
E.  G.  C.  W.,  M.  D. 


PREFACE  TO  SECOND  EDITION. 

Certain  portions  of  this  book  have  been  reorganized,  and  there 
have  been  added  descriptions  of  the  Albumin  Sputum  Test  for 
Tuberculosis,  Bass  and  Watkins'  Rapid  Widal  Method,  Noguchi's 
Butyric  Acid  Test  for  Syphilis,  and  the  Urobilinogen  Test  for 
Hepatic  Function. 

Furthermore,  an  attempt  has  been  made  to  meet  some  of  the 
needs  of  the  amateur  analyst;  and  for  this  reason  a  few  tests 
have  been  added  in  the  form  of  an  appendix,  which  includes  a 
Bedside  Method  for  the  Estimation  of  the  Urinary  Acidity,  a 
very  valuable  Indican  Test,  a  simple  Test  for  Indolacetic  Acid,  a 
consideration  of  the  Bence-Jones  Albumose  Body,  the  Sulphosa- 
licylic  Acid  Test  for  Urinary  Albumin,  and  the  Hermann-Perutz 
Serum  Test  for  Syphilis. 

B.  G.  R.  W.,  M.  D. 
E.  G.  C.  W.,  M.  D. 
April,  1913. 


CONTENTS 


CHAPTER  I. 

PAGE 

GENERAL  CONSIDERATIONS 13 

CHAPTER  II. 
THE  SPUTUM 27 

CHAPTER  III. 
SEARCHING  FOR  GERMS 3/ 

CHAPTEK  IV. 
VASCULAR  DRAMAS 53 

CHAPTER  V. 
CHEMISTRY  AND  BIOLOGY  OF  THE  GASTRIC  JUICE 71 

CHAPTER  VI. 
ESSENCE  OF  TISSUE  DIAGNOSIS 78 

CHAPTER  VII. 
DETECTION  OF  THE  COMMON  POISONS 85 

CHAPTER  VIII. 
EXUDATES   ix  BRIEF 94 

CHAPTER  IX. 
DIAZO  VERSUS  WIDAL 100 

CHAPTER  X. 
THE  URINE  IN  DISEASE 107 

CHAPTER  XL 
MILK  AND  ITS  HOME  MODIFICATIONS „ 125 

CHAPTER  XII, 
SO.UE  SIMPLE  TATATEB  ANALYSES  .  138 


8  CONTENTS 

CHAPTER  XIII. 

PAGE 

EVERY-DAY  STOOL  TESTS 148 

CHAPTER  XIV. 
TECH  NIC  OF  THE  PRIVATE  POST-MORTEM 156 

CHAPTER  XV. 
To  FIND  THE  TREPOXEMA  IN  Six  MINUTES 171 

CHAPTER  XVI. 
LABORATORY  PROPHYLAXIS 177 

CHAPTER  XVII. 
INDICATIONS  FOB  LABORATORY  AIDS 182 

CHAPTER  XVIII. 
GENERAL  INFORMATION  .     .     .     .     .     .     .    • .     .186 


ILLUSTRATIONS. 

FIG.  PAGE 

1  Giant  alcohol  burner 17 

2  Kerosene  mantle  burner 17 

3  Portable  microscope 19 

4  Physician's   laboratory 22 

5  Apparatus  for  sputum  analysis 28 

C     Elastic  tissue  and  sputum  findings 30 

7  Apparatus   for  bacteriological   examinations 36 

8  A  streak  culture 38 

9  Correct  method  of  inoculating  a  tube 39 

10  Surface  colonies  of  diphtheria  bacillus 44 

11  Some  of  the  more  common  forms  of  the  diphtheria  bacillus       ...     45 

12  Typical  fir  tree  tetanus  stab  in  gelatin 46 

13  Apparatus  for  blood  examinations 52 

14  Development  of  the  blood  cells 54 

15  Scheme  for  rapid  counting  of  red  cells 61 

1C     Spreading 63 

17  Artifacts  in  blood  films 64 

18  Authors'  slide  forceps 66 

19  Apparatus  for  stomach  analysis 70 

20  Method  of  removing  contents  from  stomach 73 

21  Microscopic  elements  of  major  and  minor  import  in  stomach  analysis     74 

22  Substitutes  for  the  perfected  microtome 79 

23  Apparatus  for  detection  of  common  poisons 86 

24  Improvised  Marsh  apparatus 89 

25  Puncture  of  pleura 95 

26  Diagram  showing  site  of  lumbar  puncture 96 

27  Apparatus  for  urinalysis 106 

28  Modification  of  Boston's  pipette  test  for  albumin       .      .      .      .   •  .      .111 

29  Artifacts -.      .    118 

30  Some  typical  epithelial  cells  from  the  urinary  passages        .      .      .      .119 

31  Comparison  of  the  more  usual  forms  of  the  common  crystals  met  in 

urinary  sediments 120 

32  Tube  for  fat  estimations 135 

9 


10  ILLUSTRATIONS. 

FIG.  PAGE 

33  Tapeworms  compared  with  vegetable  fibers 151 

34  Ova  of  the  most  common  intestinal  worms  compared  with  a  red  blood 

cell 152 

35  Scalp  incision 160 

36  Removing  the  skull  cap 162 

37  Initial  incision 164 

3fif    Examination  of  the  heart 165 

39  Apparatus  for  finding  treponema  pallidum 170 

40  Making  the  suspension 172 

41  Spreading  the  mixture 173 

42  Treponema  pallidum 175 

43  Five-inch  test  tube,  with  various  amounts  of  liquid 186 


INTRODUCTION. 

BY   VICTOR    C.    VAUGHAN,    M.  D. 

It  gives  me  great  pleasure  to  write  a  short  note  of  approval  of 
this  book.  It  has  been  said  that  the  general  practitioner  is  passing 
away,  but  this  statement  is  certainly  negatived  by  this  book.  There 
is  nothing  more  hopeful  in  the  practice  of  medicine  today  than  the 
thorough  way  in  which  many  general  practitioners  are  doing  their 
work.  There  are  many  small  cities,  and  even  villages,  in  which 
there  are  general  practitioners  who  have  equipped  themselves  with 
most  effective  laboratories.  This  volume  shows  that  the  working 
laboratory  in  which  the  best  work  may  be  done  can  be  established 
at  a  small  cost.  It  requires  only  a  good  man  to  conduct  it.  It 
would  be  regrettable  were  it  true  that  the  country  doctor  has  ceased 
to  do  scientific  work.  Jenner  was  a  village  doctor  when  he  tested 
and  demonstrated  the  efficiency  of  vaccination  for  smallpox.  Pas- 
teur had  shown  himself  a  great  scientist  before  he  ever  saw  Paris. 
Koch  was  a  stabsarzt,  remote  from  any  great  medical  center,  when 
he  devised  solid  culture  media  for  the  growth  of  bacteria,  and 
opened  up  a  method  of  scientific  investigation  which  has  given  such 
brilliant  results.  Sims  was  a  practitioner  in  the  then  village  of 
Montgomery,  Alabama,  when  he  worked  out  the  technic  of  the  suc- 
cessful operation  for  vesico-vaginal  fistula.  Long  was  a  rural  doc- 
tor in  Georgia  when  he  first  removed  a  tumor  under  general  anes- 
thesia. Pollender  was  a  country  doctor  when  he  first  studied  the 
blood  of  animals  sick  with  anthrax,  and  demonstrated  rod-like 
organisms  in  the  same.  Beaumont  was  an  army  surgeon,  stationed 
at  an  isolated  post  on  the  Island  of  Mackinac,  in  the  then  territory 
of  Michigan,  when  he  made  his  now  classical  experiments  upon 
Alexis  St.  Martin.  Indeed,  if  we  take  away  from  medicine  the  con- 
tributions to  that  science  made  by  physicians  far  removed  from 
great  commercial  centers,  wre  rob  it  of  half  its  glory  and  its  honor. 

This  little  volume  shows  how  the  general  practitioner  can,  at  a 
very  small  cost,  equip  a  laboratory  in  which  he  can  do  most  excel- 

11 


12  INTRODUCTION. 

lent  work.     It   demonstrates   that  costly   apparatus   and   marble 
rooms  are  not  necessary  for  the  prosecution  of  scientific  medicine. 

It  gives  me  great  pleasure,  after  a  careful  reading  of  the  proof, 
to  commend  most  highly  this  volume. 

ANN  ARBOR,  MICHIGAN. 


LABORATORY  METHODS. 


CHAPTER  I. 

GENERAL  CONSIDERATIONS. 

McDowell,  who  performed  the  first  ovariotomy,  had  not  at  his 
elbow  the  nickel-plated  sterilizer  and  the  gowned  assistant,  but  to 
his  ears  came  the  mutterings  of  a  mob  which  had  sworn  to  take 
his  life  if  he  failed  in  the  operation.  Sims  worked  and  enjoyed 
his  labors  under  circumstances  that  would  have  deterred  many 
physicians,  and  Beaumont  had  not  the  advantage  of  even  an  occa- 
sional visit  to  the  city  clinics. 

Medical  analyses,  meaning  those  procedures  where  chemistry  and 
microscopy  are  used  to  aid  in  making  correct  diagnoses,  have  gained 
an  important  position — too  important  to  be  ignored  or  turned 
mutely  over  to  the  expert. 

LABORATORY  EQUIPMENT. 

When  purchasing  laboratory  equipment,  it  is  advisable  to  pro- 
ceed carefully.  Too  many  laboratories,  especially  those  which  fail 
to  give  satisfactory  results,  are  fitted  too  hurriedly.  While  it  is 
not  suggested  to  pay  high  prices  for  a  popular  trademark,  some 
very  worthless  apparatus  is  being  sold.  Stains,  as  well  as  solu- 
tions for  quantitative  work,  should  be  purchased  in  liquid  form 
ready  for  use,  and  a  number  of  reputable  firms  prepare  good 
reagents. 

In  this  book,  where  possible,  the  English  system  of  weights  and 
measures  has  been  used. 

The  authors  have  listed  several  departments  in  order  that  the 
various  needs  of  physicians  may  be  met,  as  it  is  much  better  to 
become  expert  in  blood  analyses  alone  than  to  conduct  incompletely 
several  lines  of  work. 

13 


14  LABORATORY    METHODS. 

Microscope. — The  microscope,  once  a  luxury,  is  now  imperative 
for  a  safe  diagnosis.  It  may  be  purchased  for  less  than  the  more 
elegant  examining  chairs,  and  is,  to  say  the  least,  just  as  neces- 
sary. A  good  instrument  may  be  had  for  $80,  this  price  including 
the  third  or  oil  immersion  objective — not  a  necessity,  but  certainly 
a  convenience.  For  ordinary  work  a  movable  stage  is  unnecessary, 
though  many  men  who  have  not  been  forced  to  work  without  it 
would  not  agree  with  this  conclusion.  It  is  well  to  remember  that 
Americans  make  good  lenses. 

Glassware. — A  few  cents  will  buy  a  stock  cf  glass  tubing  and 
stirring  rods,  and  gray  filter  paper  is  cheap.  A  glass  funnel  and 
one  or  two  graduates  are  very  convenient. 

Centrifuge. — A  hand  centrifuge,  with  extra  milk  tube,  may  be 
purchased  at  a  low  figure.  Sedimentation  glasses  are  possible, 
though  not  ideal,  substitutes,  and  when  collecting  urinary  sedi- 
ments a  little  thymol  should  be  added  to  prevent  fermentation. 
Not  only  does  the  centrifuge  save  time,  but  serves  to  "bring 
down"  elements  which  would  otherwise  remain  suspended  in  the 
sedimentation  glass. 

Slides. — Glass  slides  and  covers  are  obtainable  at  any  physicians' 
supply  house,  and  cost  very  little.  For  the  finer  work  these  slides 
should  not  be  too  thick.  On  the  other  hand,  a  piece  of  window 
glass  2x2  inches  serves  well  for  urine  examinations.  Slides  which 
have  been  used  should  not  be  cast  aside  as  worthless.  If  per- 
manent preparations  have  not  been  made,  a  little  alkali  solution 
will  remove  smears  of  bacteria  or  blood.  If  these  have  been  fixed 
or  stained,  the  solution  may  be  made  stronger.  Balsam  may  be 
removed  by  xylol.  A  dip  in  grain  alcohol  may  precede  washing 
in  water. 

Accessories. — The  following  are  some  of  the  laboratory  acces- 
sories, with  prices: 

File  for  glass  work 05 

Platinum    wire    30 

Evaporating  dish    !•"> 

Ring   stand    equipped $1.00 

The  selection  of  rings  for  the  ring  stand  should  include  a  special 
clamp  to  serve  as  a  buret  support. 

Cleaning  Glassware. — Money  and  t;me  will  be  saved  by  cleanli- 
ness. For  glassware,  hot  suds  followed  by  hot  water  are  best. 


GENERAL   CONSIDERATIONS.  15 

Polish  with  a  soft,  dry  cloth.     Strong  mineral  acids  will  remove 
organic  matter. 

Stains. — Wright's  blood  stain,  carbol-gentian  violet,  fuchsin,  and 
methylene  blue  are  necessary  for  the  blood  and  bacteriological 
work.  For  tissues,  carbol  thionin  gives  a  beautiful  effect.  Hema- 
lum  or  alum  carmine  may  be  substituted,  and  then  the  prepara- 
tion stained  with  eosin  if  a  beautiful  permanent  mount  is  desired. 
Alcohol,  carbol-xylol,  and  balsam  are  necessary  only  in  case  the 
preparation  is  to  be  filed.  Balsam  should  not  be  bought  in  bottles, 
but  in  tubes,  in  order  to  prevent  waste  and  decoloration  as  well  as 
contamination,  etc.  A  paper-filtered  balsam  is  most  transparent. 
A  spatula  or  section  lifter  may  prevent  the  ruining  of  many  thin 
sections.  It  is  well  to  remember  that  in  case  the  stain  should  be 
overturned  and  spilled,  recourse  may  be  had  to  certain  anilin  inks. 
For  this  purpose  eosin,  gentian  violet,  fuchsin,  and  certain  other 
stains  may  be  obtained  in  every  hamlet,  and  extraneous  matter 
removed  by  filtration.  Good  liquid  stains  should,  however,  be  used 
when  possible.  Certain  fabric  dyes  have  been  used  to  demonstrate 
the  gonococcus.  India  ink  and  its  American  substitutes  do  not 
stain  microorganisms,  but  have  been  recommended  as  a  substitute 
for  the  high-priced  dark  field  attachments  in  searching  for  the 
treponema  pallidum. 

Substitutes. — Ccmmon  blotters  may  be  used  to  take  up  excess 
liquids.  A  brandy  bottle  makes  a  good  flask  unless  contents  are 
to  be  boiled,  a  procedure  rarely  or  never  necessary  in  clinical 
analyses.  Whisky  goblets  may  be  used  as  beakers  when  titrating" 
or  as  wash  dishes,  while  saucers  serve  as  watch  glasses.  Small 
new  tin  ointment  boxes,  such  as  are  used  in  dispensing,  may  be 
substituted  unless  acids  are  used,  the  bright  background  forming 
an  excellent  contrast  to  the  floating  sections.  Two-ounce  bottles — 
round  or  square,  to  prevent  overturning — serve  well  for  liquid 
•reagents.  Small  salt-mouth  bottles  or  granule  bottles  are  best  for 
solids.  Raised  glass  labels  are  unnecessary,  but  glass  stoppers, 
especially  for  the  stronger  acids  and  alkalies,  are  imperative.  It 
is  advisable  to  keep  only  a  small  quantity  of  the  reagent  in  the 
bottle  which  is  to  be  used  in  order  to  guard  against  evaporation, 
contamination,  or  spilling.  Stock  reagents  should  be  kept  in  a 
dry  basement  during  the  summer  months,  and  never  exposed  to 
the  light. 

Indicators. — A  dilute  solution  of  phenolphthalein  is  the  cheap- 


16  LABORATORY    METHODS. 

est,  as  well  as  the  best,  chemical  indicator.  When  the  solution  is 
acid  or  neutral,  it  is  colorless.  Alkalinity  results  in  a  red  colora- 
tion. Litmus  paper  is  too  crude  for  medical  work. 

Cover  Glasses. — Round  cover  glasses  are  well  adapted  for  smears, 
but  the  squares  are  more  convenient  for  tissue  sections.  They 
may  be  cleaned  by  immersion  in  a  little  alcohol,  rinsing  in  hot 
water,  and  polishing  with  a  dry,  soft  cloth.  A  "linty  rag"  should 
be  avoided,  as  vegetable  fibers  do  not  add  to  the  beauty  of  the 
miscroscopic  field.  It  does  not  follow,  however,  that  in  the  event 
such  contamination  occurs  the  physician  should  confuse  these  with 
elastic  fibers  or  urinary  casts. 

Pipettes. — Medicine  droppers  serve  well  as  pipettes,  both  for 
staining  and  for  transferring  liquids.  One  delicately  graduated 
pipette  is  necessary  for  stomach  work. 

Apparatus  Cabinet. — An  old  bookcase  will  serve  well  to  keep 
dust  off  apparatus,  as  a  general  house  cleaning  preliminary  to  a 
test  should  not  be  necessary.  The  inside  of  this  case  should  be 
painted  white  and  the  outside  black. 

Laboratory  Nostrums. — The  "general  stain-all,"  the  "glass 
cleaners,"  and  many  other  preparations  offered  to  the  indifferent 
practitioner  may  be  aptly  termed  "laboratory  nostrums."  The 
secret  "blend"  and  the  advanced  price  seem  to  be  the  only  dis- 
tinctions from  those  efficient  formulas  well  known  to  all  scientific 
students.  The  urinary  test  tablets  should  be  avoided. 

Suggestions. — In  each  chapter  helpful  suggestions  have  been 
made  in  regard  to  good,  but  not  expensive,  apparatus.  The  diffi- 
culties in  technic  most  liable  to  be  met  by  the  practitioner  are 
pointed  out,  and  methods  suggested  as  to  how  these  may  be  over- 
come. 

Stock  analytic  outfits  selected  by  supply  houses  should  not  be 
purchased.  The  urinary  analysis  hand  case  will  rarely,  if  ever, 
be  taken  from  the  physician's  office,  and  is  not  adapted  for  prac- 
tical work.  Such  selection  should  be  made  as  will  meet  the  re- 
quirements of  the  individual  physician,  reagents  should  be  obtained 
in  fresh  condition,  and  both  time  and  money  will  be  saved. 

Appropriate  substitutes  for  the  unavailable  articles  of  equipment 
will  constantly  suggest  themselves  to  the  resourceful  man,  and  t lie- 
physician  who,  in  an  emergency,  finds  that  he  may  inoculate  a 
tube  by  means  of  a  hat  pin  instead  of  a  platinum  point  brings  as 
much  honor  to  the  disciples  of  Esculapius  as  does  he  who  ampii- 


GENERAL   CONSIDERATIONS. 


17 


tates  with  butcher  knife  and  meat  saw  the  gangrenous  limb  of  the 
frontiersman.  As  in  other  branches  of  medicine,  intellect  first — 
equipment  later. 


Substitutes  for  Gas  and  Running  Water. 

Gas. — The  authors  have  demonstrated  that  gas  is  not  only  un- 
necessary, but  sometimes  undesirable,  in  laboratory  work.  In  the 
large  laboratory  it  is  convenient, 
and,  when  satisfactory,  should  be 
used.  The  country  physician  has 
recourse  to  alcohol  and  gasoline. 
The  small  spirit  lamp  is  inexpen- 
sive, may  be  taken  to  the  bedside, 
uses  only  a  small  quantity  of  alco- 
hol, and  does  not  place  him  at  the 
mercy  of  some  gas  plant  engineer. 
There  will  be  no  "water  in  the 
pipes,"  no  "cut  outs,"  and  no 
"meters."  Various  modifications 
of  the  alcohol  lamp  are  marketed. 
A  portable  burner 
with  a  wall  tank  can 

be  had  (Fig.  1),  the  reservoir  holding  about  a  quart 
of  denatured  alcohol,  from  which  a  flame  four  times 
as  intense  as  that  of  the  ordinary  Bunsen  burner 
may  be  obtained. 

For  continuous  heating,  a  single-burner  gasoline 
stove  is  ideal.  A  kerosene  burner  fails  as  a  sub- 
stitute, as  its  flame  is  usually  inaccessible.  A  uro- 
tropin  tablet,  burned  in  the  air,  will  heat  to  boiling 
the  contents  of  three  test  tubes  successively  ap- 
plied. This  tablet  should  be  placed  on  a  glass  or 
metallic  plate,  or  in  a  medicine  spoon.  Poor  grades 
of  this  drug  .have,  however,  a  tendency  to  explode ; 
throwing  burning  particles  in  all  directions. 

Gas  is  not  necessary  for  incubators  (page  21), 
and  neither  is  it  required  for  illuminating  pur- 
poses. By  properly  manipulating  the  mirror,  con- 
denser,  an^  diaphragm,  smears  and  sections  may  be 


Fig.  1. — Giant  alcohol  burner.  Its  flame 
is  four  times  as  intense  as  that  of 
the  ordinary  Bunsen  gas  burner. 


18  LABORATORY    METHODS. 

examined  by  the  ordinary  kerosene  lamp.  The  authors  have  tested 
with  the  most  gratifying  results  the  various  mantle  kerosene 
burners,  one  of  which  is  shown  in  Fig.  2,  and  do  not  hesitate  to 
recommend  them  to  all  microscopists  as  the  best,  and  yet  the  most 
economical,  of  lights. 

Running  Water. — A  city  water  supply  may  be  aptly  termed  a 
laboratory  luxury,  and,  when  obtainable,  is  not  to  be  despised.  A 
siphon  system,  operated  from  a  large  bottle  on  a  shelf,  with  a  rub- 
ber tube  and  a  pinch  cock,  will,  however,  answer  very  well.  In 
staining,  wash  glasses  (whisky  glasses  containing  water)  will  save 
many  steps.  A  large  bowl  of  clean  water  serves  well  for  washing 
sections  and  smears,  as  anilin  stains,  when  much  diluted,  are  prac- 
tically inert.  Blood  pipettes  may  be  cleaned  without  the  aid  of 
running  water  (see  page  62).  Centrifugalization  need  not  depend 
on  water  pressure. 

Essentials  of  Practical  Microscopic  Technic. 

Mirror. — The  plane  mirror  is  the  one  usually  employed,  espe- 
cially when  examining  stained  preparations.  The  concave  mirror 
is  preferred  when  using  artificial  light  or  when  examining  tissue 
sections.  In  the  latter  case  it  is  best  to  swing  aside  the  condenser 
and  narrow  the  aperture  of  the  iris  diaphragm. 

Illumination. — Direct  sunlight  should  never  strike  the  mirror. 
The  best  angle  for  the  reflection  of  light  is  as  it  comes  from  a 
white  cloud  (Novy).  A  white  window  shade  will  often  be  a  great 
aid,  especially  in  a  south  room. 

Condenser. — Fig.  3  illustrates  the  portable  microscope.  The 
stage  has  been  tilted  in  such  a  manner  that  the  condenser  and  its 
control  B  are  seen  to  best  advantage.  The  use  of  the  condenser 
usually  comes  with  experience,  but  it  should  always  be  adjusted 
when  beginning  work.  The  man  who  "plays"  with  his  condenser 
will  soon  become  expert  in  its  use.  A  correct  focus  of  the  con- 
denser is  as  important  as  the  objective  focus.  Neither  increases 
the  magnification,  but  both  serve  to  render  distinct  the  smear  or 
section. 

Iris  Diaphragm. — This  is  rarely,  if  ever,  opened  wide.  Correc- 
tion of  illumination  is  very  often  necessary  in  seeming  indications 
for  a  widened  aperture.  With  a  slightly  constricted  diaphragm  a 
stained  object  is  rendered  more  distinct,  and,  when  examining  un- 


GENERAL   CONSIDERATIONS. 


19 


Fig.  3. — Portable  microscope.     A,  to  adjust  draw  tube;  B,  to  control  condenser;  C,  dia- 
phragm; D,  coarse  adjustment;  E,  fine  adjustment. 

stained  preparations,  further  narrowing  is  necessary,  as  that  field 
is  bathed  in  a  dim  twilight,  the  best  possible  illumination  for  such 
examinations. 

Ocular. — This  regulates,  to  some  extent,  the  magnification.     The 


20  LABORATORY    METHODS. 

various  oculars  are  numbered  differently  according  to  the  make  of 
the  instrument.  It  is  of  advantage  in  diagnostic  work  to  change 
oculars  frequently. 

Objective. — The  use  of  the  objective  is  usually  so  well  under- 
stood that  its  description  is  omitted.  The  objective  perfects  the 
image,  the  latter  lying  just  below  the  ocular. 

Focusing. — This  does  not  mean  merely  a  lowering  or  raising  of 
objective,  but  also  an  adjustment  of  the  condenser.  It  is  a  good 
plan  to  make  the  final  adjustment  of  the  condenser  after  the  objec- 
tive is  in  proper  position  in  order  to  obtain  the  most  perfect  image. 
It  is  usually  advantageous  to  begin  the  study  of  a  preparation  with 
the  lowest  power  and  then  proceed  to  higher  magnifications.  A 
good  procedure  for  "safe"  focusing  is  offered  by  Stitt:  "It 
should  be  an  invariable  rule  for  the  worker  to  bring  his  objective 
practically  into  contact  with  the  upper  surface  of  the  cover  glass, 
using  the  coarse  adjustment  to  slowly  elevate  it  into  focus,  and 
then  maintain  this  focus  with  the  micrometer  screw." 

Cleaning  Lenses. — Expensive  lens  paper  is  unnecessary.  An  un- 
starched, but  clean,  linen  handkerchief  is  much  better.  Oils  are 
best  removed  with  the  aid  of  a  similar  cloth  previously  moistened 
in  a  little  alcohol;  if,  however,  it  is  applied  to  the  tube,  the  alcohol 
quickly  destroys  the  lacquer.  Warm  water  and  a  soft  cloth  re- 
move agar-agar  and  gelatin.  Balsam  is  not  so  easily  conquered, 
and  must  be  avoided.  Carbol-xylol  will  dissolve  it,  but  its  fre- 
quent use  dissolves  the  cement  which  secures  the  lenses  and  may 
eventually  loosen  them. 

Cover  Glasses. — These  should  be  used  invariably,  especially  when 
working  with  the  higher  powers,  as  they  render  the  object  much 
more  distinct.  Prior  to  their  use  a  drop  of  water  or  balsam  must 
be  placed  on  the  preparation.  Thick  cover  glasses  interfere  with 
high-power  focusing  and  must  not  be  used.  Round  cover  glasses 
are  used  for  smears  of  pus ;  for  tissue  section  squares  are  preferable. 

Microscopic  Hysteria  (Microscopic  Cephalalgia) . — This  is  not 
usually  an  idiosyncrasy,  but  results  from  one  or  more  well-known 
causes.  It  may  be  due  to  an  uncorrected  error  of  refraction,  to 
improper  illumination,  malposition  of  condenser,  or  an  open 
diaphragm.  A  severe  headache  may  arise  from  an  accommodation 
squint.  If  one  eye  is  closed,  it  soon  becomes  fatigued  because  the 
working  eye  must  accommodate.  A  dark  glass  worn  over  the  un- 
employed eye  will  often  relieve  this  condition.  Both  eyes  should 


GENERAL   CONSIDERATIONS.  21 

be  open.  It  is  a  good  plan  to  alternate  the  use  of  one  eye  with 
the  other. 

Laboratory  Tables. — These  should  be  painted  black,  but  walls 
should  be  of  a  light  tint. 

Miscellaneous  Rules. — The  following  rules  should  be  carefully 
observed. 

1.  Use  microscope  in  a  vertical  position,  and  slide  clamps  will 
not  be  necessary. 

2.  Use  a  chamois  skin  to  polish  lacquer. 

3.  Keep  fingers   oft'  lacquer,   and  carry  the  microscope   by  its 
handle. 

4.  Do  not  lay  a  slide  on  the  stage  until  its  under  surface  is 
known  to  be  dry. 

5.  A  microscope,  when  not  in  use,  must  be  kept  from  dust  by 
placing  it  either  in  its  case  or  under  a  bell  jar. 

A  Bacteriological  Laboratory  for  Five  Dollars. 

Five  dollars  or  less  will  buy  everything  necessary  for  a  phy- 
sician's bacteriological  laboratory — microscope  not  included.  The 
bugbear  in  considering  such  a  laboratory  has  been  the  incubator, 
and  this  matter  has  usually  been  presented  to  the  general  prac- 
titioner in  a  discouraging  manner.  The  fact  is,  however,  that  all 
that  is  necessary  is  some  method  of  maintaining  cultures  at  a  con- 
stant temperature  of  98.6°  F. — i.  e.,  at  blood  heat. 

During  the  hot  summer  months  no  such  contrivance  is  necessary, 
and  for  other  times  of  the  year  many  substitutes  for  the  $50  gas 
incubator  may  be  made.  For  example,  a  chicken  incubator  will 
serve  the  same  purpose,  a  kerosene  "germ  warmer"  that  will  an- 
swer is  on  the  market,  and  a  high  candle  power  electric  bulb  may 
be  immersed  in  a  pan  of  water  and  the  heat  regulated  by  adding 
or  removing  water.  A  certain  poultryman  was  able  to  hatch 
chicks  in  a  bee  hive  from  the  heat  given  off  by  these  insects,  and, 
although  the  establishment  of  an  apiary  in  a  clinical  room  is  not 
recommended,  the  method  is  not  without  a  lesson.  Perfect  cul- 
tures of  the  diphtheria  bacillus  have  been  obtained  in  an  office 
slightly  overheated  by  an  ordinary  round  stove,  and  an  instance 
is  known  where  a  man  carried  a  living  culture  of  the  typhoid 
bacillus  safely  through  a  blizzard  by  means  of  a  special  pocket  in 
his  underwear.  A  considerable  fall  in  temperature,  though  inhib- 


22 


LABORATORY    METHODS. 


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GENERAL    CONSIDERATIONS.  23 

iting  the  growth  of  many  microorganisms,  does  not  necessarily 
result  in  their  death.  These  facts  account  for  the  possibility  of 
mailing  diphtheritic  material  to  far  distant  laboratories,  the  reten- 
tion of  the  virulence  of  "spoiled"  ice  cream,  etc. 

A  fireless  cooker  will  serve  to  keep  plate  cultures  at  a  growing 
temperature,  and  for  tubes  the  vacuum  bottle  has  been  recom- 
mended, which  is  not  only  convenient,  but  has  the  advantage  of 
being  well  adapted  for  refrigerative  purposes. 

The  hot  air  sterilizer  may  be  easily  dispensed  with,  as  there  is 
no  better  sterilizer  for  test  tubes,  metal  ware,  flasks,  and  cover 
glasses  than  a  small  gasoline  oven,  which  may  be  heated  with  a 
gasoline  or  alcohol  burner. 

Culture  media  should  be  obtained  from  a  reputable  firm  in 
assorted  lots  of  a  dozen,  which  will  save  considerable  expense  and 
trouble  that  would  be  incurred  in  an  attempt  to  prepare  them. 
After  using  these  media  the  cultures  may  be  killed  and  the  tubes 
cleaned  for  chemical  analyses. 

The  following  estimate  of  prices  of  accessories  should  be  con- 
sidered by  the  practitioner : 

Vacuum  bottle    $1.95 

Gasoline  oven 1.25 

Alcohol   stove    1.76 

Six  tubes  of  culture  media 30 

Platinum    loop    30 


$5.55 

Arrangement  for  a  Physician's  Laboratory. 

The  idea  that  the  clinical  laboratory  must  be  a  separate  institu- 
tion is  erroneous.  Its  location  need  not  be  seclusive,  nor  need  it 
be  even  separated  from  the  consultation  room.  One  side  of  the 
ordinary  examining  room  may  be  devoted  to  laboratory  purposes, 
and  the  light  side  should,  of  course,  be  chosen.  An  ideal  arrange- 
ment is  shown  in  Fig.  4. 

A  shelf  table,  without  legs,  should  be  made  to  run  the  entire  length 
of  the  laboratory  space.  Cypress  is  the  best  wood  for  its  construc- 
tion, and  it  should  measure  about  20  inches  in  width.  It  should 
be  at  a  height  convenient  for  the  "standing"  analysis,  and  a 
high  stool,  when  desirable,  may  be  used  for  the  microscopic  examina- 
tions. 


24  LABORATORY    METHODS. 

At  one  end  of  this  shelf  table  should  be  located  the  apparatus 
cabinet,  and  the  sink  is  built  into  the  other  end.  All  apparatus 
should  be  kept  free  from  dust  in  the  cabinet,  at  least  a  portion  of 
which  should  be  covered  with  glass. 

The  shelf  table  should  be  securely  fastened  to  the  wall  in  order 
that  there  be  no  legs  to  trip  the  foot  or  thwart  the  broom,  and  a 
small  quantity  of  black  paint  will  add  the  finishing  touches.  Such 
a  laboratory  table  will  require  little  or  no  room,  as  examining 
chairs,  bandage  or  dressing  tables,  etc.,  may  be  placed  under  it 
when  these  are  not  in  use. 

In  case  sunlight  is  direct  and  blinding,  white  shades  may  be 
drawn  over  the  windows. 

The  shelf  can  be  easily  kept  clean  with  a  chamois,  slightly  damp- 
ened, and  formalin  added  to  the  water  not  only  inhibits  or  kills 
pathogenic  microorganisms,  but  will  destroy  odors  of  pus,  urine, 
etc. 

Offensive  specimens  of  excretions  or  bits  of  diseased  tissue  should 
be  kept  from  the  view  of  patients. 

During  a  urinalysis  the  samples  should  be  kept  in  amber  or  blue- 
colored  glass  bottles  or  jars.  A  "stinking"  sample  of  urine  is 
rarely  excusable.  Except  in  some  forms  of  cystitis  or  gynecologic 
conditions,  a  freshly  voided  urine  never  smells.  If,  however,  an 
analysis  of  a  bad-smelling  specimen  is  necessary,  it  should  be  de- 
ferred until  an  hour  when  visitors  are  most  unlikely  to  enter. 
After  such  analysis  there  should  be  a  thorough  aeration  of  the 
room,  for  which  purpose  the  following  formula  is  a  most  excellent 
deodorizer : 


E  lodoform $  j 

Oil  of  spearmint ad  saturated  solution 

Sig. :   Nebulize,  vaporize,  or  otherwise  distribute  throughout  the 
room. 


The  physician  should  remember  that  most  reagents  are  freezable, 
with  the  following  notable  exceptions:  carbol-xylol ;  alcohol  and 
alcoholic  stains  and  solutions;  ether;  solutions  containing  glycerin 
—for  example,  Haines'  solution. 

Laboratory  reference  books  should  be  kept  with  the  laboratory 
equipment,  ready  for  convenient  reference.  This  book  was  not 
written  for  the  bookcase,  but  was  intended  to  lie  on  the  table 


GENERAL    CONSIDERATIONS.  25 

within  easy  reach  of  the  physician.  On  the  laboratory  walls  may 
be  hung  charts  of  bacteria,  solubility  tables,  etc. 

Most  solutions  and  stains  should  be  kept  only  in  small  quantities 
on  account  of  evaporation,  precipitation,  etc.  Haines'  solution 
should  be  prepared  fresh  in  small  amounts  every  few  months. 

Further  laboratory  suggestions  have  been  made  in  succeeding 
chapters.  For  example,  directions  for  the  care  of  blood  pipettes 
occur  in  Vascular  Dramas  (page  62),  principles  of  asepsis  and 
antisepsis  occur  in  Searching  for  Germs  (page  42),  etc. 

LABORATORY  EXPERTS. 

Before  giving  a  description  of  the  various  tests  it  seems  advisable 
to  sound  a  word  of  warning  in  regard  to  a  subject  about  which 
there  seems  to  be  much  confusion — laboratory  experts.  Modern 
medicine,  especially  its  laboratory  branches,  is  built  on  a  scientific 
foundation ;  in  fact,  its  progress  is  a  history  of  the  progress  of 
prophylaxis  and  diagnostics,  each  physician  having,  to  some  extent, 
his  own  ideas  regarding  therapeutics.  There  was  a  time  when  a 
certain  mysticism  was  associated  with  sending  a  specimen  to  some 
prominent  chemist  for  a  test,  but  now  medical  students  are  trained 
to  perform  and  understand  these  tests.  A  physician  should  per- 
form all  the  tests  which  present  knowledge  and  equipment  place 
within  his  reach ;  but  what  shall  he  do  when  he  is  not  prepared 
to  make  some  important  investigation  ? 

Practitioners  are  cautioned  against  some  laboratories.  To  state 
a  diagnosis  to  a  patient  means  to  pass  judgment,  and  is  a  serious 
matter.  In  case  the  physician  has  not  the  time  or  is  not  prepared 
for  a  certain  investigation,  he  should  exercise  care  as  to  whom  he 
calls  into  consultation.  In  the  first  place,  he  should  studiously 
avoid  the  ordinary  chemist  or  the  chemical  supply  house,  and 
should  seek  the  medical  specialist.  The  institution  which  asks  no 
remuneration  for  its  services  should  be  avoided,  although  this  may 
not  be  advisable  when  dealing  with  patients  unable  to  pay  the 
necessary  fees.  A  curt  "positive"  or  "negative"  from  some 
student,  or  from  a  favorite  of  unknown  ability,  not  only  means 
nothing  to  the  conscientious  therapeutist,  but  such  report  is  usually 
so  misleading  as  to  be  dangerous.  Indeed,  if  as  much  care  were 
taken  in  the  proper  selection  of  consultants  in  diagnostics  as  in 
the  field  of  surgery,  or  in  the  department*  nf  ophthalmology  and 


26  LABORATORY    METHODS. 

otology,  our  medical  successes  would  more  than  compensate  for 
such  efforts. 

It  may  be  well  before  leaving  this  subject  to  caution  physicians 
against  the  sending  of  specimens  to  sanitariums  or  other  institu- 
tions whose  ultimate  aim  may  be  to  secure  for  themselves  the  pa- 
tients from  whom  the  specimens  were  taken.  The  same  caution 
will  apply  to  reports  from  tent  colonies  concerning  sputum  exami- 
nations or  to  reports  from  certain  mineral  springs  in  regard  to 
urinalyses,  as  these  reports  are  liable  to  be  biased  and  their  recom- 
mendations be  accordingly  unsafe. 

The  physician  should  personally  do  as  much  as  possible  of  his 
analytical  work,  and  should  spare  neither  time,  money,  nor  study 
to  become  a  safe  diagnostician.  The  practical  information  pre- 
sented in  this  book  will  aid  him  in  his  endeavors,  and,  in  case 
expert  help  becomes  necessary,  the  best  help  obtainable  should  be 
secured.  Patients  will  appreciate  intelligent  treatment  and  will 
be  willing  to  pay  accordingly. 


CHAPTER  II. 


THE  SPUTUM. 
Apparatus. — Does  not  include  that  used  in  the  albumin  test. 


1.  Glass  plate. 

2.  Teasing    needles     (sharp    hat    pins 

make  excellent  substitutes). 

3.  Platinum  loop. 

4.  Black     laboratory    table    or     card 

board. 

5.  Slides. 

6.  Round  cover  glasses. 


7.  Carbol-gentian  violet. 

8.  Dilute  nitric  acid. 

9.  Very  dilute  acid  fuchsin. 

10.  Ordinary  blotting  papers. 

11.  Several  whisky  glasses. 

12.  Cover  glass  forceps. 

13.  Flame. 

14.  Microscope  and  accessories. 


Scope  of  Work. — The  arrangement  of  apparatus  is  shown  in 
Fig.  5.  Those  tests  will  be  described  which  are  most  commonly 
needed  by  the  practitioner,  and  less  frequently  applied  procedures, 
including  those  usually  left  to  experts,  are  merely  listed. 

Obtaining  the  Sputum. — Give  the  patient  15  grains  of  potassium 
iodid  at  bedtime,  and,  if  possible,  repeat  this  dose  at  about  2 
o'clock  the  following  morning.  This  drug  is  preferably  given  in 
milk.  On  rising  in  the  morning  the  patient  should  wash  out  his 
mouth  with  a  little  soda  water,  being  careful  not  to  hawk  up  at 
the  time  any  sputum.  The  sputum  is  then  collected  in  a  wide- 
mouth  vaselin  bottle.  Saliva  is  not  wanted.  Sputum  should  be 
coughed  up  or  raised  by  hawking.  It  is  manifestly  a  waste  of 
time  to  examine  oral,  nasal,  and  pharyngeal  secretions  for  evidences 
of  pulmonary  involvement. 

Quantity. — This  is  so  variable  in  the  several  stages  of  lung  dis- 
eases as  to  be  of  little  diagnostic  import.  A  very  small  quantity 
of  true  sputum  is  the  rule  in  incipient  tuberculosis. 

Consistence. — Here,  again,  are  variations.  When  the  sputum  is 
very  thin  and  watery,  showing  a  tendency  to  froth,  there  is  a 
probability  of  pulmonary  edema.  Pus  is  easily  divided  into  drops 
with  the  aid  of  a  pipette,  but  mucus  has  a  tendency  to  cling,  not 


References. — Sahli :   Diagnostic  Methods:   Von  Jaksch:   Diagnostics;   Boston:   Clinical 
Diagnosis;  Wood:  Chemical  and  Microscopical  Diagnosis. 

27 


28 


LABORATORY    METHODS. 


THE   SPUTUM.  29 

only  to  other  matter  (adhesion),  but  is  separated  into  drops  with 
difficulty  (cohesion). 
Color. 

Color.  Cause.  Significance. 

Translucent  and  slimy. .  Mucus     Variable. 

Black     Soot Normal     in     some     occupa- 
tions. 
Rusty,     prune     juice,     or 

yellow     Changed   blood    Usually  pathological. 

Green     Hemorrhage  or  icterus . .  Pathological. 

Gray    Pus    Pathological. 

Red    Blood     Pathological. 

Small  clumps  of  a  bright-green  color  may  often  be  observed  in 
influenza. 

Odor. — Sputum  is  odorless,  except  when  it  becomes  contami- 
nated with  putrefying  microorganisms,  which  may  be  observed 
in  pulmonary  gangrene  or  bronchiectasis.  Sometimes  a  sputum, 
after  standing  for  a  few  hours,  unless  kept  on  ice,  becomes 
soured.  The  authors  have  seen  a  drop  of  secretion  from  a  fetid 
rhinitis  contaminate  an  odorless  sputum  to  such  an  extent  as 
to  render  examination  almost  impossible. 

Albumin  Sputum  Test. — Soluble  albumin  in  the  sputum  is 
identified  in  much  the  same  manner  as  in  urine,  but  because  of 
the  presence  of  mucus,  specimens  of  sputum  are  filtered  with  dif- 
ficulty, so  that  it  is  necessary  to  modify  the  technic  somewhat. 
In  a  large  test  tube,  five  drams  of  physiologic  salt  solution,  five 
c.c.  of  sputum  and  five  drops  of  acetic  acid,  are  well  shaken  for 
five  minutes.  It  is  easy  to  commit  to  memory  this  technic  when 
the  quantities  are  thus  remembered  in  fives,  though  the  measure- 
ments do  not  need  to  be  accurate.  Shake  well,  filter  and  test  the 
filtrate  for  albumin  by  any  of  the  tests  which  may  be  applied  for 
serum  albumin  in  the  urine.  In  chronic  cases  where  uncompen- 
sated  valvular  lesions  and  nephritis  may  be  ruled  out,  the  posi- 
tive reaction  invariably  means  tuberculous  involvement  of  the 
lungs  as  albumin  is  not  met  in  chronic  bronchitis.  It  is  usually 
present  in  acute  diseases  of  the  'lungs  and  bronchi,  and  is  of 
practically  no  differential  value  except  in  protracted  conditions. 

Searching  for  Elastic  Tissue. — Pour  all  the  sputum  on  the  glass 
plate  and  set  this  plate  on  a  black  surface  for  examination.  A 


30 


LABORATORY   METHODS. 


laboratory  table  painted  black  will  answer  the  purpose.  Next 
tease  out  the  solid  portions  of  the  specimen  with  needles.  Bits  of 
elastic  tissue — i.  e.,  lung  tissue — appear  usually  as  yellowish  gran- 
ules. Very  rarely  they  may  be  tinged  with  red  blood  or  may  be 
hardened  (calcification).  These  bits  of  tissue  should  be  selected 


Fig.  6. — Elastic  tissue  and  other  sputum  findings  with  which  it  may  be  confused.  A, 
elastic  fibers,  with  acute  branchings  and  ends  resembling  fish-hooks,  seen  only  when 
diaphragm  is  narrowed,  and  in  a  moderate  light  they  show  a  double  contour;  B, 
fibrinous  bronchial  cast ;  C,  molds ;  D,  mucous  spiral ;  E,  cotton  fibers,  extraneous, 
and  usually  come  from  the  towel  used  in  wiping  laboratory  glassware;  F,  linen  fibers. 

out,  and  examined  for  the  typical  yellow  fibers.  Low  power  should 
be  used,  and,  if  the  field  is  well  illuminated,  the  diaphragm  should 
be  somewhat  narrowed.  Food  particles,  actinomycotic  granules, 
tonsil  plugs,  etc.,  may  be  mistaken  for  these  particles  of  lung  tissue. 
Under  low  power  the  elastic  fibers  refract  light  in  such  a  manner 
as  to  make  them  appear  double,  which  can  not  be  properly  shown 
in  a  drawing.  In  Fig.  6  elastic  fibers  are  shown,  and  their  ap- 
pearance is  so  characteristic  that  confusion  with  the  other  ele- 
ments in  this  figure  is  rarely  excusable.  Their  broken  ends  tend 


THE   SPUTUM.  31 

to  curl  into  a  form  not  unlike  that  of  a  fish-hook,  and  branching 
at  acute  angles  may  also  be  noted.  "When  once  recognized,  they 
do  not  usually  cause  confusion  in  future  examinations. 

Significance  of  Elastic  Tissue. — Its  presence  in  sputum  means, 
invariably,  the  coughing  up  of  diseased  lung  tissue,  and  signifies 
usually  the  presence  of  Koch's  bacillus.  Elastic  tissue  may  some- 
times be  found  in  nontuberculous  abscess,  rarely  in  pulmonary 
gangrene,  and  never  in  normal  sputum. 

Preparing  the  Spreads. — Pick  out  suspicious  particles  with  a 
platinum  loop  which  has  been  previously  sterilized  in  the  flame 
and  then  cooled.  Spread  these  well  on  clean  round  cover  glasses 
and  allow  them  to  dry.  Do  not  neglect  to  heat  the  loop  to  redness 
before  laying  it  aside.  When  thoroughly  dried,  pass  these  cover 
glasses,  with  the  specimen  side  up,  rapidly  through  the  flame  sev- 
eral times,  taking  care  not  to  burn  the  preparation.  A  brownish 
coloration  indicate*  that  the  preparation  has  been  ruined.  The 
cover  glass  should,  however,  feel  hot  to  the  finger,  and  this  heat 
fixation  not  only  glues  the  preparation  to  the  glass,  but  causes  the 
stain  to  hold. 

Staining  the  Preparation. — The  following  modification  of  the 
Ziehl-Neelsen  method  and  its  congeners  has  given  the  authors  the 
best  results : i 

Seize  the  cover  slip  with  forceps  and  lock.  Hold  specimen  side 
up,  and  cover  it  with  a  few  drops  of  carbol-gentian  violet.  Hold 
above  the  flame  in  such  a  manner  that  it  steams,  but  does  not  boil. 
This  height  is  soon  learned,  and  varies  with  the  intensity  of  the 
flame.  Replace  with  a  medicine  dropper  any  of  the  stain  lost  by 
evaporation.  After  steaming  for  three  minutes,  the  excess  stain 
is  poured  off  and  the  preparation  is  ready  to  go  through  the 
washes.  The  latter  are  contained,  most  advantageously,  in  small 
tumblers,  and  the  actual  process  is  that  of  paddling  gently  each 
different  liquid  with  the  preparation.  Each  specimen  should  go 
through  the  following  washes : 

1.  "Water,  one  minute. 

2.  Dilute  nitric  acid  until  only  a  bluish  tint  remains. 

3.  Ethyl  alcohol,  50-percent,  two  seconds. 

4.  "Water  immediately  (not  that  used  in  1),  two  minutes. 


1  This  same  technic  is  applicable  where  the  physician  prefers  to  stain  with  earbol- 
fuchsin  and  counterstain  with  methylene  blue  or  bismarck  brown.  It  is  occasionally  ad- 
visable to  apply  both  methods  to  the  same  specimen  in  case  any  doubt  exists. 


32  LABORATORY    METHODS. 

5.  Acid  fuchsin  solution,  oue-half  minute. 

6.  Water,  two  minutes. 

Dry  the  preparation  between  two  ordinary  blotters  and  examine, 
mounted  either  in  water  or  balsam.  The  tubercle  bacilli  should 
appear  as  small,  slender  violet  rods  on  a  pink  background.  Oil 
immersion  objective  should  be  used  in  the  examination. 

To  Prepare  Dilute  Nitric  Acid. — Add  four  drops  of  concen- 
trated nitric  acid  to  each  half  ounce  of  water. 

Carbol- Gentian  Violet. — Use  the  liquid  stain  as  prepared  by 
some  responsible  company. 

To  Prepare  Acid  Fuchsin  Solution. — Use  1  part  of  the  alcoholic 
solution  to  20  parts  of  water.  Filter  if  necessary.  Dilute  picric 
acid  makes  even  a  more  beautiful  counterstain,  but  does  not  stain 
properly  other  microorganisms.  It  should  be  used  only  by  one 
who  has  learned  to  recognize  the  tubercle  bacillus  by  its  mor- 
phology as  quickly  as  by  its  staining  characteristics  and  who  has 
thoroughly  mastered  the  technic. 

The  Findings. — It  is  not  sufficient  that  Koch's  bacillus  is  absent 
or  present.  Is  there  a  secondary  infection,  or  is  any  purulent  in- 
fection which  may  be  present  the  primary  condition  ?  What  germ 
is  causing  the  symptoms?  What  is  its  degree  of  virulence  ?  What 
stage  of  tuberculosis  is  present?  Is  there  caseation  or  lapidifica- 
tion?  Types  of  white  blood  cells  are  of  some  import,  and  many 
polymorphonuclears  are  more  apt  to  indicate  secondary  infection 
than  a  few  lymphocytes.  Records  of  over  one  thousand  analyses 
made  by  the  authors  indicate  that  correct  diagnostic  and  prog- 
nostic conclusion^  were  often  obtained  from  corpuscular  elements 
alone.  The  following  table  illustrates  some  of  these  findings : 

Phthisis.  Purulent  infections. 

Elastic  tissue   None. 

Lapidification    (lung   stones) None. 

Tacillus  tuberculosis Nonucid  fast  cocci  or  bacilli,  among 

which  certain  types  usually  predomi- 
nate. 

Caseous  masses None. 

Blood    (red  cells) None. 

Lymphocytes  Pus  cells — i.  e.,  disintegrating  poly- 

morphonuclear  leukocytes. 

Appearance  of  the  Tubercle  Bacilli. — These  tend  to  occur  in 
clumps.    Each  measures  in  length  about  one-half  the  diameter  of 


THE    SPUTUM.  33 

a  red  blood  cell,  and  often  presents  a  beaded  appearance  or  shows 
a  slight  curving  of  the  ends.  While  branched  forms  have  been 
observed,  they  rarely  branch.  In  very  virulent  strains  they  may 
appear  to  be  shortened  even  as  coccus-like  bodies  (exaltation), 
and,  when  but  slightly  virulent,  show  tendencies  to  produce  in- 
volution forms,  as  Schron's  capsules  (attenuation). 

The  presence  of  the  pneumococcus  in  large  numbers  in  a  tuber- 
culous sputum  would  seem  to  indicate  an  unfavorable  prognosis, 
but  the  authors  have  been  unable  to  demonstrate  this  theory — pos- 
sibly because  such  a  warning  usually  stimulated  vigorous  prophy- 
lactic and  therapeutic  measures.  Incubation  or  centrifugalization 
of  a  sputum  often  aids  in  the  finding  of  the  tubercle  bacillus. 

Less  Frequently  Applied  Procedures. — These  include  those  ex- 
aminations rarely  attempted  and  also  those  usually  left  to  the  ex- 
pert. In  rare  instances  the  physician  may  desire  to  search  for  the 
actinomyces  clubs  or  the  echinococcus  booklets.  A  description  of 
these  should  hardly  occupy  a  place  in  this  work,  but  the  following 
list  of  less  frequently  applied  procedures  is  given : 

1.  Curschmann's  spirals  in  bronchial  asthma. 

2.  Heart  failure  cells  in  valvular  lesions. 

3.  Other  vegetable  parasites,  as  diplococcus  pneumonia,  bacillus 
influenzas,  and  certain  molds. 

4.  Animal  parasites,  as  ameba  coli,  etc. 

5.  Certain  crystals  of  little  or  no  diagnostic  importance. 

6.  Albumin  tests. 

General  Sputum  Difficulties. — For  those  who  have  difficulty  in 
finding  Koch 's  bacillus,  there  seems  but  one  remedy — be  sure  of  the 
technic.  The  correct  procedure  may  be  determined  by  taking  a 
sputum  known  to  contain  tubercle  bacilli  and  making  several 
dozen  good  stains  from  it.  While  making  these  stains  the  tech- 
nic will  be  mastered.  It  is  surprising  how  expert  a  physician 
may  become  after  one  afternoon's  practice  and  how  many  hours 
of  needless  labor  he  may  avoid  in  the  future. 

Some  persons  do  not  work  with  a  system,  and  a  negative  result 
will  be  discouraging  simply  because  a  repetition  of  the  work  means 
another  half  hour  of  application  to  the  technic.  Apparatus  should 
be  arranged  to  save  time,  and  should  be  kept  clean  and  properly 
classified  for  use.  Several  spreads  may  be  made  and  fixed  at  one 
time,  so  that  if  the  first  stain  fails  it  will  not  be  necessary  to  hunt 
up  the  sample — or  possibly  the  patient — for  another  test. 


34  LABORATORY   METHODS. 

Difficulties  in  Spreading. — There  is  a  tendency  to  spread  too 
thickly.  A  droplet  of  the  sputum — not  a  drop — should  be  used. 
An  attempt  should  be  made  to  cover  every  bit  of  the  cover  glass 
surface,  and  a  film  so  thin  as  to  be  almost  invisible  is  most  likely 
to  give  the  best  results. 

Difficulties  in  Drying. — These  difficulties  are  more  serious  than 
may  appear  at  first  thought,  and  it  is  in  this  part  of  the  technic  that 
many  failures  occur.  It  is  obvious  that  a  thin  spread  dries  much 
quicker  than  a  thick  one.  Drying  should,  however,  be  thorough, 
and  it  is  not  sufficient  that  no  water  be  visible.  There  may  be  some 
moisture  present — enough  to  interfere  with  proper  fixation.  It  is 
a  safe  rule  to  wait  at  least  twenty  minutes  after  all  moisture  has 
apparently  disappeared  before  fixing  the  specimen. 

Difficulties  in  Fixation. — These  difficulties  have  been  emphasized 
under  description  of  the  method  of  fixation  (page  31).  Inciner- 
ation, or  overfixation,  is  recognized  by  the  loss  of  characteristic 
morphology  of  the  spread  elements.  Underfixation  is  not  impos- 
sible, and  is  shown  by  a  tendency  of  the  smear  not  to  stain,  or, 
when  stained,  to  readily  lose  the  dye.  "When,  after  staining,  any 
motions  of  the  spread  elements  are  observed,  the  physician  may 
feel  certain  that  the  fixation  has  not  been  complete.  Although  the 
proper  fixing  temperature  is  learned  by  experience,  a  safe  rule  is 
that  the  cover  glass  be  hot,  but  that  the  preparation  be  not  burned. 

Difficulties  in  Staining  and  Washing. — If  the  stain  contains 
sediment,  filter  it,  and,  if  it  seems  to  be  too  thin,  obtain  some  fresh 
stain.  Although  it  must  steam,  ebullition  renders  the  specimen 
unfit  for  examination  because  pieces  of  it  are  dislodged  and  float 
off  in  the  stain.  Do  not  allow  any  portion  of  the  preparation  to 
become  dry,  but  add  a  drop  of  stain  as  needed.  Two  or  three 
minutes  usually  suffice  for  this  procedure.  Pour  off  the  excess 
stain  and  wash  immediately  in  water.  Let  this  washing  be 
thorough,  so  that  any  precipitated  stain  may  be  removed,  as  such 
particles  may  be  easily  mistaken  for  caseated  masses,  or  even 
microorganisms. 

When  the  nitric  acid  causes  the  stain  to  fade  appreciably,  dip 
twice  in  dilute  alcohol  and  immediately  wash  briskly  in  clean 
water.  It  may  be  added  that  one  of  the  most  beautiful  stains  ever 
seen  by  the  authors  was  made  by  a  physician  who,  finding  that 
his  supply  of  alcohol  had  become  exhausted,  substituted  gin. 

If  a  light-blue  remains,  transfer  to  fuchsin,  but,  if  the  prepara- 


THE   SPUTUM.  35 

tion  is  still  dark,  wash  once  more  in  the  nitric  acid  solution.  The 
preparation  may  not  be  entirely  ruined  even  if  no  blue  is  discerni- 
ble, and  it  should  not  be  decolorized  again  merely  because  a  few 
blue  lumps  occur.  These  overstained  areas  indicate  thick  spread- 
ings,  and  should  not  be  taken  into  account  at  the  final  examination. 

Difficulties  in  Mounting. — The  slide  should  be  clean.  A  droplet 
—not  a  drop — of  balsam  should  be  used.  Apply  the  cover  glass 
lightly,  and  do  not  press  it  into  place.  In  the  colder  months  the 
balsam  may  not  spread,  and,  if  such  be  the  case,  warm  the  slide 
slightly.  If  an  air  bubble  clings  to  the  balsam  droplet,  a  pin 
prick  will  cause  its  disappearance. 

To  Reclaim  a  Preparation. — Several  smears  should  be  spread 
and  fixed  at  one  time.  If  the  preparation  has  been  mounted  in 
balsam,  it  may  be  difficult  to  put  it  into  a  suitable  condition  for 
restaining,  and  soaking  it  in  carbol-xylol  may  aid  in  removing  the 
balsam.  One  unaccustomed  to  this  work  may  examine  the  stains 
in  water  instead  of  balsam. 

Value  and  Limitation  of  the  Sputum  Analysis. — Tubercle  bacilli 
are  often  absent  in  incipient  phthisis,  but  the  number  of  such  in- 
stances recorded  has  been  improperly  increased  by  the  reports  of 
persons  who  used  faulty  technic  or  made  wrong  observation. 

It  is  often  advisable  to  substitute  for  the  fuchsin  counterstain 
an  aqueous  picric  acid  solution.  This  does  not,  however,  properly 
stain  the  other  microorganisms,  but,  if  the  technic  has  been  thor- 
oughly mastered,  this  disadvantage  is  more  than  offset  by  the  ease 
with  which  the  tubercle  bacillus  may  be  demonstrated — a  bright- 
purple  rod  on  a  lemon-yellow  background.  A  deeply  stained  epi- 
thelial cell  to  which  Koch's  bacillus  shows  a  tendency  to  cling  can 
not  hide  it  if  this  method,  as  proposed  by  Mix,  is  followed. 

The  finding  of  elastic  fibers  is  indicative  of  "coughed-up"  lung, 
providing  the  vomiting  of  meat  foods  has  not  occurred  during  the 
coughing  up  of  the  sputum,  a  matter  that  should  be  determined. 

It  may  be  accepted  as  a  rule  that  the  finding  of  acid  fast  bacilli 
in  the  sputum  indicates  pulmonary  tuberculosis.  Other  acid  fast 
bacilli  are  more  likely  to  be  found  in  pharyngeal  secretions  than  in 
true  sputum.  The  smegma  bacillus  does  not  show  a  curling  of  the 
ends,  nor  does  it  lie  in  clumps.  In  case  of  doubt,  other  acid  fast 
bacilli  may  be  excluded  by  decolorizing  with  the  alcoholic  solution 
of  hydrochloric  acid  described  under  tuberculosis  of  the  urinary 
organs.  (See  The  Urine  in  Disease,  page  123.) 


LABORATORY  METHODS. 


CHAPTER  III. 


SEARCHING  FOR  GERMS. 


Apparatus.— 

1.  Aqueous     solution     of     10-percent 

sodium  hydroxid. 

2.  Cover  glass   forceps. 

3.  Culture  media,  prepared  and  ster- 

ilized.     (See   page   23.) 

4.  Dish   of    1:1,000   bichlorid   of   mer- 

cury solution,  colored  blue. 

5.  Flame. 

G.  Gasoline    oven    designed    for    one 
burner. 

7.  Incubator       or       substitute.      (See 

page  21.) 

8.  Microscope   and   accessories. 

!i.   .Mason     jar     for     unused     culture 
tubes. 


10.  Ordinary     Fahrenheit     thermome- 

ter. 

11.  Pan  for  boiling  water. 

12.  Petri  dishes. 

13.  Platinum  point  or  loop,  or  both. 

14.  Slides  and  cover  glasses. 

15.  Stains     and     pipettes — methylene 

blue,    Lomer's    methylene    blue, 
Wright's  blood  stain. 

16.  Glass  tumbler  with  cotton  in  bot- 

tom for   supporting  test   tubes, 
platinum  wire,  pipettes,  etc. 

17.  Uterine  spoon  curet. 


The  arrangement  of  apparatus  is  shown  in  Fig.  7.  In  this  chap- 
ter will  be  described  in  a  plain,  but  thorough,  manner  some  of  the 
bacteriological  examinations  which  may  be  made  by  the  country 
physician.  Investigations  requiring  much  time,  expense,  and  con- 
siderable skill  are  not  included  in  these  examinations,  and  animal 
inoculation  experiments  are  avoided.  The  study  of  the  micro- 
organisms of  the  bacillus  tuberculosis,  treponema  pallidum,  dip- 
lococcus  intracellularis,  and  plasmodium  malarias  will  be  found  in 
The  Sputum  (page  32),  Vascular  Dramas  (page  67),  Exudates  in 
Brief  (page  97),  and  To  Find  the  Treponema  in  Six  Minutes  (page 
173). 

Culture  Media. — These  may  be  obtained  from  certain  pharma- 
ceutical houses  in  assorted  tubes  of  a  dozen  and  properly  sterilized 
for  use.  The  following  selection  should  be  kept  on  hand  and  avail- 
able at  a  moment's  notice: 


References. — Jordon :     General     Bacteriology;     Stitt:     Practical     Bacteriology;     Novy: 
Laboratory  Bacteriology;   McFarland:   Bacteriology;   Muir  and  Ritchie:   Bacteriology. 

37 


38 


LABORATORY    METHODS. 


Nutrient  agar,  four  tubes. 

Loffler's  serum  agar  and  swabs,  four  tubes. 

Glucose  agar,  two  tubes. 

Nutrient  gelatin,  two  tubes. 

These  media  should  be  kept  in  a  glass  jar  free  from  dust,  and 
the  rubber  caps  which  prevent  the  ingress  of  the  air  should  not  be 
removed  until  the  media  are  to  be  used.  After  a  few  months  these 
media  "dry  out"  and  should  then  be  replaced  with  new  material. 

Influences  Which  Inhibit  Germ  Growth.— 

1.  Absence  or  presence  of  oxygen,  depending  on  whether  germ  is 
aerobic  or  anaerobic.     The  only  anaerobic  germ  considered  in  this 
book  is  the  tetanus  bacillus. 

2.  High  or  low  temperatures.     The  body  temperature  is  most 
favorable  to  the  cultivation  of  pathogenic  microorganisms. 

3.  Light.     Bacteria  work  best  in  the  dark,  and  sunlight  is  their 

worst  enemy. 

Inoculation  of  Tubes. — With  a  bit  of  the 
material  on  a  sterile  platinum  wire,  inocula- 
tion of  suitable  media  may  be  accomplished 
by  any  one  of  several  methods : 

1.  HORIZONTAL    STREAK.     The    contaminated 
wire  is  drawn  across  a  plate   (Petri  dish)    of 
culture  media.     Each  germ  develops  a  colony 
where  it  happens  to  fall. 

2.  STAB.     The  contaminated  wire  is  pushed 
down  the  center  of  solid  culture  media  in  a 
tube.     Such    a    method    is    well    adapted    for 
anaerobic  germs. 

3.  INCLINED    STREAK    (Fig.    8).     This   is   a 
very  convenient  method  for  the  rural  worker, 
as    purchased    media    in    tubes    are    usually 
slanted.     The  wire  bearing  the  suspected  mi- 
croorganisms is  drawn  along  the  center  of  this 
surface  from  the  bottom  upward.     The  follow- 
ing technic   is   followed   when  inoculating   by 
this  method: 

First.  Sterilize  the  wire  in  the  flame  and 
hold  with  the  right  band  in  such  a  manner 
that  contamination  is  improbable. 

Fig.  8.-A  streak  culture.          8ecMtd'      The    tube    is   held    in    the    left    hand 


SEARCHING    FOR   GERMS. 


39 


between  thumb  and  index  finger,  with  plugged  end  toward  the 
right.  It  should  be  held  in  a  position  almost  horizontal,  so  that 
it  may  not  be  contaminated  by  falling  dust  particles  when  the  plug 
is  removed. 

Third.  Remove  and  discard  the  rubber  cap.  The  cotton  plug 
is  grasped  between  the  middle  and  third  fingers  of  the  right  hand 
and  quickly  removed  with  a  sharp  twist. 


Fig.  9. — Correct  method  of  inoculating  a  tube. 

Fourth.  Hold  the  neck  of  the  tube  in  the  flame  for  a  moment 
in  order  to  incinerate  any  microorganisms  which  may  be  attempt- 
ing to  gain  entrance. 

Fifth.  Now  inoculate  the  .tip  of  the  sterile  wire  with  the 
smallest  bit  of  the  suspected  material  and  streak  the  agar  as  de- 
scribed above,  being  careful  not  to  contaminate  anything  (Fig.  9). 
Especially  avoid  air  currents,  and  do  not  allow  the  platinum  point 
to  touch  the  side  of  the  tube. 

Sixth.     Withdraw  wire. 

Seventh.     Again  pass  neck  of  tube  through  flame. 

Eighth.     Insert  cotton  plug. 


40  LABORATORY   METHODS. 

Ninth.     Sterilize  wire  in  flame. 

The  entire  technic,  when  properly  learned,  should  take  only 
about  one  minute,  and  should  be  conducted  with  care.  The  in- 
oculated tube  should  be  kept  at  body  temperature  for  twenty-four 
hours. 

Small  colonies  should  mark  the  path  of  the  wire.  Unless  the 
least  amount  of  the  suspected  material  has  been  used,  these  will, 
because  of  their  great  number,  coalesce  and  render  isolation  of 
the  causative  germ  impossible.  A  platinum  point  is,  therefore, 
more  desirable  than  a  loop.  Separation,  if  necessary,  must  be  done 
at  once,  as  overcrowding  as  well  as  the  presence  of  involution 
forms  will  occur  as  time  passes. 

Isolation  of  Pure  Cultures. — Specimens  from  the  various  colo- 
nies may  be  examined  at  once,  and  this  is  usually  an  advisable 
procedure  in  diagnostic  work.  It  may,  however,  be  the  desire  of 
the  worker  to  obtain  a  pure  culture  of  the  microorganism — i.  e., 
where  the  tube  contains  only  this  germ  and  coalescence  of  colonies 
does  not  cause  contamination — which  may  be  done  as  follows: 

First.  Place  several  tubes  of  nutrient  agar  upright  in  a  can  of 
boiling  water.  When  liquefaction  of  the  media  has  occurred,  per- 
mit the  water  to  cool  down  to  about  122°  F.  This  is  the  inoculat- 
ing temperature,  solidification  occurring  as  cooling  progresses  be- 
low this  point. 

Second.  Meanwhile,  with  a  hand  lens,  study  the  colonies  on 
the  original  slanted  surface.  Some  may  be  round  and  others 
irregular,  some  transparent  and  others  opaque,  and  some  flat  and 
others  raised.  A  certain  germ  invariably  gives  rise,  in  its  growth, 
to  a  colony  typical  of  its  species,  and  inoculations  from  a  single 
colony  should  result  in  a  pure  culture  of  that  germ.  In  case  all 
colonies  appear  alike,  the  primary  inoculation  was  possibly  a  pure 
culture. 

Third.  When  the  melted  agar  reaches  122°  F.,  inoculations 
should  be  made  at  once  according  to  the  method  described  above. 
In  this  case  a  platinum  point,  rather  than  a  loop,  should  be  dipped 
into  the  colony,  as  otherwise  too  many  microorganisms  will  be  ob- 
tained. Each  inoculation  should  be  mixed  well  into  the  agar,  and 
the  wire  resterilized  in  the  flame  before  inoculating  the  next  tube. 

Fourth.  The  liquid  agar,  thus  inoculated,  is  immediately  (after 
heating  neck  of  tube)  poured  into  a  Petri  dish  that  has  been 
previously  heat  sterilized.  The  tube  is  then  thrown  into  a  strong 


SEARCHING    FOR   GERMS.  41 

solution  of  mercuric  chlorid  and  later  cleansed  by  boiling.  The 
Petri  dish  is  immediately,  with  its  contents  (plate  preparation), 
set  aside  at  blood  heat.  Other  dishes  are  inoculated  in  the  same 
way. 

The  above  technic  requires  haste,  as  the  agar  cools  rapidly  and 
solidifies. 

Authors'  Short  Method. — The  authors  are  convinced  that,  for 
practical  purposes,  the  above  plating  is  not  always  necessary.  The 
process  is  tedious,  and,  though  usually  described  as  the  standard 
method,  offers  so  many  opportunities  for  contamination  that  the 
practitioner  is  ji  stified  in  seeking  further  for  a  substitute. 

In  this  be i  tae  statement  has  been  emphasized  that,  although 
isolaM'vi  of  pare  cultures  is  not  a  necessary  procedure  in  many 
diagnostic  problems,  the  worker  soon  takes  pride  in  this  separation. 
If,  however,  such  isolation  is  avoided,  an  early  examination  of 
specimens  from  the  colonies  is  often  imperative  for  the  reason  that 
coalescence  .of  colonies  and  involution  forms  of  the  germs  occur. 
A  simple  method  of  isolating  pure  cultures  is  to  select  samples 
from  the  various  colonies  and  inoculate  other  agar  slants  "When 
this  work  is  done  early  and  carefully,  it  will  not  be  subject  to  criti- 
cism. 

Incubation  in  Vacuum  Bottles. — Reference  has  been  made  to 
substitutes  for  the  expensive  and  complex  sterilizer  and  incubator. 
If  a  so-called  vacuum  bottle  or  a  fireless  cooker  be  employed,  it 
will  be  necessary  to  see  that  the  cultures  are  obtaining  a  proper 
amount  of  oxygen.  Such  an  incubator  should  be  kept  in  a  warm 
room,  and  the  cork  or  lid  inserted  only  after  both  the  culture  and 
the  inclosed  air  are  warm.  The  required  warmth  may  be  secured 
with  a  slightly  heated  stove.  It  may  be  advisable  to  have  this 
temperature  a  little  higher  than  98.6°  F.,  as  some  cooling  will 
always  occur.  In  order  to  insure  plenty  of  oxygen,  it  is  best  to 
"reincubate"  at  least 'once  during  the  twelve  hours  or  twice  dur- 
ing the  twenty-four  hours.  A  little  sweet  oil  heated  to  body 
temperature  may  be  placed  in  the  bottom  of  the  vacuum  bottle, 
but  plenty  of  air  must  he  left  above  the  surface  for  the  use  of  the 
developing  colonies. 

Sterilization. — 1.  NUTRIENT  MEDIA.  These  should  be  purchased 
ready  for  use. 

2.  GLASSWARE  AND  METALWARE.  These  should  be  boiled  for  at 
least  ten  minutes,  making  sure  that  all  portions  are  touched  by  the 


42  LABORATORY    METHODS. 

water,  after  which  they  are  cleaned  and  dried.  Contamination 
with  various  atmospheric  bacteria  occurs  during  the  cleaning,  so 
that  Petri  dishes  and  other  glassware  treated  in  this  manner  are 
not  available  for  further  culture  work  without  hot  air  sterilization 
just  before  using.  The  sterilization  may  be  conducted  in  a  gaso- 
line oven,  provided  that  sufficient  time  and  care  be  taken.  The 
degree  of  heat  required — about  300°  F. — necessitates  removal  of 
all  cotton  plugs  and  organic  material.  Glassware,  but  not  metal- 
ware,  may  be  immersed  in  a  strong  solution  of  mercuric  chlorid 
before  boiling,  which  does  not  usually  kill  the  germs,  but  weakens 
them  to  such  an  extent  that  they  easily  succumb  to  the  boiling 
water. 

3.  COVER   GLASSES.     These,   when   cleaned   and   dried,   may   be 
passed  through  the  flame  several  times  preliminary  to  making  a 
spread,  and  may  be  heated  past  the  fixing  point,  so  that  all  organic 
material  is  destroyed.     After  cooling,  they  are  practically  sterile 
and  the  spread  may  be  made  at  once. 

4.  TOWELS.     These  may  be  dipped  into  the  mercury  solution, 
but  a  thorough  boiling  should  never  be  omitted.     During  the  boil- 
ing every  portion  should  be  immersed  in  the  water. 

5.  HANDS.     During  culture  work  the  hands  should  not  come  in 
direct  contact  with  any  sterile  apparatus,  nor  with  any  suspected 
virulent   material.     The   fingers   should   not   touch   the   platinum 
loop,  lower  end  of  the  cotton  plug,  inside  of  the  tubes,  or  Petri 
dishes  known  to  be  sterile,  and  should  not,  of  course,  come  in  con- 
tact  with   colonies,    pus,    etc.     At   frequent  intervals   the   hands 
should  be  scoured  with  a  brush  and  hot  suds.     Unless  mercuric 
chlorid  causes  dermatitis  in  the  worker,  he  may  keep  a  1 : 1,000 
solution  conveniently  near,  into  which  to  dip  his  hands  occasionally, 
and  thus  inhibit  the  effect  of  any  germ  which  might  alight  at  the 
mouth  of  a  sweat  gland.     For  convenience  of  distinction,  a  little 
blue  or  green  coloring  matter  may  be  added  to  this  solution.     The 
physician  who  looks  on  these  solutions  not  as  antiseptics,  but  as 
disinfectants,  has  something  to  learn. 

6.  METAL   INSTRUMENTS.     Except    for    the    mercury    solution, 
which  ruins  them,  these  may  be  treated  in  the  same  manner  as 
glass.     Forceps,  wires,  etc.,  may  be  heated  to  incandescence  in  the 
nonluminous  flame. 

7.  LABORATORY  TABLES.     Should  be  wiped  off  at  frequent  inter- 
vals with  a  cloth  saturated  in  1 : 500  solution  of  mercury. 


SEARCHING   FOR   GERMS.  43 

Simple  Stains. — Of  these  the  authors  prefer  methylene  blue  in 
most  diagnostic  procedures,  as  this  dye  usually  stains  well,  but 
seldom  overstains.  Other  good  stains  are  fuchsin  and  gentian 
violet.  The  methylene  blue  stain  is  prepared  by  diluting  some  of 
the  concentrated  alcoholic  solution  with  water,  the  object  being  to 
obtain  a  stain  with  little  alcohol.  It  is  best,  however,  to  dilute 
slowly  until  the  liquid  is  transparent,  as  otherwise  precipitation 
of  the  stain  wall  occur  on  the  cover  glass,  and,  if  this  happens,  re- 
ject the  stain  and  make  up  some  more,  using  less  water.  An  un- 
saturated  stock  solution  gives,  when  diluted,  a  weak  stain,  and 
hence  the  necessity  of  obtaining  these  dyes  from  a  reliable  firm. 
The  following  technic  for  staining  bacteriological  smears  will  give 
excellent  results: 

First.  Spread  thoroughly  some  of  the  material  on  a  sterile 
cover  glass  with  a  sterile  platinum  loop.  This  wire  is  always  ster- 
ilized by  heating  to  incandescence  in  the  nonluminous  flame. 
Remember  that  a  spread  is  rarely  or  never  too  thin,  but  is  often 
too  thick,  or  at  least  may  be  so  in  spots. 

Second.     Dry  in  air. 

Third.  Fix  in  flame  according  to  directions  given  under  sputum 
(page  30). 

Fourth.     Permit  preparation  to  cool. 

Fifth.  Grasp  the  glass  with  forceps  and  lock,  and,  holding 
specimen  side  up,  add  enough  stain  to  cover  the  smear. 

Sixth.  After  about  one  minute — exact  time  depending  on 
strength  of  stain — wash  off  the  dye  under  the  tap  or  dip  repeat- 
edly in  a  bowl  of  water. 

Seventh.  Dry  lower  surface  of  glass  with  a  piece  of  filter  paper 
or  an  ordinary  blotter,  invert,  and  float,  specimen  side  downward, 
onto  a  clean  slide. 

Eighth.  This  serves  as  a  diagnostic  examination.  In  case  it  is 
desired  to  keep  the  preparation,  it  may  be  dried  between  two  blot- 
ters and  mounted  in  a  droplet  of  balsam  (page  34). 

Staining  Errors. — Overstaining  with  methylene  blue  is  rare. 
Understating,  however,  is  common,  and  may  depend  on  one  of  four 
causes — overfixing,  underfixing,  a  weak  staining  fluid,  or  insuffi- 
cient time  of  exposure.  Overtaxation  is  usually  apparent  by  the 
injury  to  the  bacteria — charring,  etc.  Underfixation  permits  the 
floating  off  of  the  specimen  during  washing.  Underfixation  may 
be  microscopically  demonstrated  by  the  motility  of  the  germs,  even 


44 


LABORATORY    METHODS. 


though  partially  stained.  In  case  staining  troubles  should  con- 
tinue, it  is  possible  that  the  solution  is  too  dilute,  and  precipita- 
tion of  the  dye  may  indicate  this  condition.  In  case  the  staining 
time  was  insufficient,  the  preparation  should  take  the  dye  on  the 
second  trial. 

Other  Staining  Methods. — There  are  many  excellent  stains  in- 
dicated in  other  books,  but  which  can  hardly  be  recommended  in 
this  work  as  absolutely  necessary  for  the  diagnostician,  who  must 
reserve  many  of  his  energies  for  other  kinds  of  labor.  In  searches 
for  the  gonococcus  and  diphtheria  bacillus,  the  physician  may 
advantageously  substitute  Loffler's  methylene  blue.  Gram's  dou- 
ble stain,  spore  stains,  flagella  and  capsule  stains — and  indeed 
many  others  not  mentioned  in  this  chapter — should  be  understood 
by  the  practitioner  in  order  that  the  value  and  limitations  of  all 
bacteriological  work  may  be  borne  in  mind. 


Fig.  10. — Surface  colonies  of  diphtheria  bacillus.  These  become  quite  characteristic 
within  eighteen  hours,  while  the  other  microorganisms  may  not  yet  be  visible.  The 
colony  is  flat,  with  a  wavy  edge  and  a  dark  center.  The  contents  are  grayish  white, 
coarsely  granular,  and  not  unlike  ground  glass.  Drawn  from  an  eighteen-hour  cul- 
ture. 

Searching  for  the  Bacillus  Diphtherias. — At  least  one  physician 
in  the  radius  of  every  one  hundred  miles  should  be  prepared  for 
this  examination,  and  no  county  seat  should  be  without  a  person 
equipped  for  this  work.  The  procedure  is  not  difficult,  and,  if 
the  examination  is  conducted  by  the  physician  in  charge  of  the 
case,  it  will  be  more  valuable  than  if  made  by  a  person — often  not 
a  physician — several  hundred  miles  distant. 

A  swab  from  the  throat  may  be  tested  immediately,  as  smears 
can  be  made,  stained,  and  examined  at  once.  To  be  certain  of  the 
diagnosis,  an  inoculation  may  be  made  which,  within  eighteen 
hours,  should  show  hundreds  of  the  Klebs-Loffler  bacilli,  isolation 
in  pure  cultures  of  this  microorganism  is  not  necessary  for  the 


SEARCHING   FOR   GERMS.  45 

diagnosis  of  diphtheria.  The  serum  agar  slant  tubes  and  swabs 
may  be  purchased  with  other  media.  No  disinfecting  solutions 
are  to  be  used  on  the  throat  preliminary  to  the  swabbing,  for  which 
the  procedure  is  as  follows : 

1.  Bub  swab  over  affected  portion  of  the  throat,  removing,  if 
possible,  some  of  the  membrane. 

2.  Streak  over  surface  of  serum  agar.     Several  such  tubes  should 
be  so  prepared. 

3.  Keep    at    blood    temperature    from    eighteen   to    twenty-four 
hours. 

Diphtheria  Colony. — This  is  moist  in  appearance,  large,  round, 
and  of  grayish  color  (Fig.  10).  The  center  is  thick,  while  the 
edges  are  thin,  and  examination  with  a  hand  lens  shows  a  wavy 
border.  Cover  glass  smears  may  be  made  from  these  colonies, 
fixed,  and  stained  with  Lbffler  's  methylene  blue. 


Fig.  11. — Some  of  the  more  common  forms  of  the  diphtheria  bacillus,  reproduced  from 

actual  preparations. 

Bacillus  Diphtherias. — The  Klebs-Loffler  bacillus  shows  some  or 
all  of  the  following  characteristics  as  compared  with  other  bacilli : 

1.  Irregularity  of  form  arid  size,  illustrated  in  Fig.  11. 

2.  Club  shapes,  or  bacilli  bearing  swollen  ends. 

3.  Cross  striations  or  bands. 

4.  Monopolar  or  bipolar  staining. 

5.  Wedge  shapes. 

6.  Curved  forms. 

Certain  forms  of  bacilli — pseudo  types — may  closely  resemble 
the  true  bacillus  of  diphtheria.  Tn  case  of  doubt  their  character 
can  be  determined  by  allowing  them  to  come  in  contact  with  a  drop 
cf  water,  when  the  pseudo  type  will  form  a  cloudy  suspension, 
which  will  not  occur  with  the  true  Klebs-Loffler  bacillus. 

Searching  for  the  Bacillus  Tetani. — The  cultivation  of  the 
tetanus  bacillus  requires  the  absence  of  oxygen.  Many  methods 


46  LABORATORY   METHODS. 

have  been  devised,  but  the  method  given  here  is  suggested,  and 
smears  from  the  wound  may  be  examined.  It  is  a  well-known  fact 
that  anaerobic  germs  may  multiply  in  the  presence  of  those  requir- 
ing oxygen,  a  phenomenon  that  is  termed  "microbic  association," 
and  therefore,  if  any  tetanus  bacilli  in  the  wound  are  capable  of 
multiplying — unless  planted  very  deeply  in  the  tissues — the  pres- 
ence of  certain  oxygen-requiring  germs  is  presumed. 

1.  With  a  sterile  uterine  spoon  curet  scrape  well  the  wound, 
being  certain  that  no  antiseptic  has  been  used  previous  to  this 
procedure.     A    thorough    cauterization    for    therapeutic    purposes 
should  follow  this  curettage. 

2.  Add  some  of  this  material  to  a  tube  of  serum  agar — not  a 
slant,  but  one  which  has  been  previously  liquefied,  if  necessary,  and 
resolidified  in  a  vertical  position  (page  40). 

3.  Incubate  from  four  to  seven  days. 

4.  Examine  for  characteristic  drum-sticks,  which  are  not  easily 
found,  for,  even  if  the  culture  be  pure,  all  tetanus  bacilli  do  not 
show  the  end  spore,  and  typical  drum-sticks  often  escape  detection 
because  simple  stains  do  not  bring  out  well  the  end  spore.     Hot 
carbol-fuchsin   will   stain    both    the    spore    and   the    body.     (For 

method  see  page  31.)  The  tetanus  bacillus, 
with  or  without  a  spore,  is  usually  a  very 
long  and  slender  rod. 

5.  Heat  the  culture  in  water  up  to  175°  F. 
and  maintain  at  this  temperature   for  forty- 
five  minutes.     Only  spores  remain  viable. 

6.  After    cooling,    make    a    stab    culture   in 
glucose     agar    and     incubate.     Such     tetanus 
spores  as  may  be  present  will  develop  deep  in 
the    agar   and    show    a    cloudy    growth,    with 
characteristic    perpendicular    branchings.     Its 
indistinctness,   together  with  the  fir  tree  ap- 
pearance,   is    peculiar    to    the    microorganism. 
The  gelatin  stab  culture  is  much  more  distinct 

Fig.  12.— Typical  fir  tree      (Fig.   12). 

tetanus   stab   in   gela-  ~  „   _  „,,         .      -,     .  • 

tin.     six  days'  cui-       Sources  of  Error. — The  isolation  of  the  tet- 

ture.     Occurs  only  in  i        -n  • 

the    lowest    portions  anus    bacillus    is    not    an    encouraging    proce- 
dure, even  for  the  expert.     Strange  to  note, 
however,  the  authors  have  seen  it  identified  by  persons  who  would 
be  least   expected  to  find   it.     The  attempt  is  worth  the  effort, 


SEARCHING    FOR   GERMS.  47 

although  the  spores  of  other  anaerobes  may  interfere.  Stitt  at- 
taches importance  to  the  odors  which  may  arise  from  the  serum 
culture,  and  states:  "From  day  to  day  smell  the  culture,  and,  if 
an  odor  similar  to  the  penetrating  sour,  foul  smell  of  the  stools 
of  a  man  who  has  been  on  a  debauch  is  detected,  it  is  suspicious. 
The  nondevelopment  of  a  foul  odor  is  against  tetanus." 

Searching  for  Koch- Weeks  Bacillus. — This  may  be  necessary 
when  attempting  to  differentiate  a  severe  catarrhal  conjunctivitis 
from  a  mild  gonorrheal  infection.  Smears  from  the  secretion 
should  be  made  and  stained  for  the  gonococcus  (page  48).  If  the 
Koch-AYeeks  microorganisms,  instead  of  the  diplococci,  are  present, 
they  will  appear  as  very  short  bacilli.  If  the  gonococci  are  present, 
they  usually,  though  not  invariably,  lie  within  the  protoplasm  of 
the  pus  cells. 

Searching  for  Streptococcus  Pyogenes. — This  important  micro- 
coccus  has  been  found  in  the  following  conditions : 

1.  Diffuse  inflammations,  as  phlegmons,  erysipelas,  etc. 

2.  Inflammations  of  respiratory  tract,  as  pharyngitis,  bronchitis, 
lobular  pneumonia,  etc. 

3.  Acute  articular  rheumatism. 

4.  Uleerative  endocarditis. 

5.  Puerperal  fever. 

6.  Scarlet  fever. 

7.  Certain  inflammations  of  serous  linings,  as  peritonitis,  etc. 

Some  authorities  claim  that  the  streptococcus  pyogenes  is  a  dis- 
tinct microorganism,  being  closely  related  to  other  chain  cocci,  but 
not  identical  with  those  causing  erysipelas,  rheumatic  fever,  and 
scarlet  fever.  So  far  as  diagnostic  purposes  are  concerned,  this 
distinction  is  unimportant. 

The  streptococci  occur  normally  in  the  mouth,  nasal  cavity,  large 
intestine,  vagina,  and  on  the  integument.  The  attenuation  and 
exaltation  of  the  streptococcus  seems  an  easy  matter,  and  the 
resisting  powers  of  the  organism  need  suffer  only  slight  decrease 
to  render  it  an  easy  prey.  In  pus,  search  first  for  the  staphylococ- 
cus  and  then  for  the  streptococcus,  but  follow  vice  versa  in  the 
diffuse  and  more  extended  inflammations.  The  isolation  and  identi- 
fication of  this  coccus  by  cultural  examination  is  hardly  to  be 
recommended  to  the  country  physician,  as  there  are  so  many  sources 
of  error  and  so  many  limitations.  Smears  stained  with  methylene 
blue  offer  a  much  better,  though  still  imperfect,  method.  Usually, 


48  LABORATORY    METHODS. 

though  not  invariably,  the  long  chains  of  streptococci,  compared 
with  the  short  chains  of  less  than  eight  cocci,  are  the  really  dan- 
gerous forms,  but  it  has  been  proven  that  virulent  short  chains  do 
exist. 

Searching  for  Staphylococci. — This  is  the  most  common  of  all 
pus  germs,  and  for  practical  purposes  need  not  be  divided  into 
subclasses.  It  is,  however,  interesting  to  note  that  furuncles  and 
other  abscesses  of  the  integument  are  due  usually  to  the  varieties 
which  form  yellow  colonies,  while  those  of  pharyngeal  infections 
are  white.  Suspected  pus  may  be  inoculated  into  nutrient  agar  by 
following  the  directions  applying  to  diphtheria.  The  opaque 
creamy-white  or  light-yellow  colonies  are  most  likely  to  show  the 
staphylococcus.  Both  forms  liquefy  gelatin,  and  often  the  germ 
may  be  found  in  the  pus  smears. 

While  methylene  blue  serves  well  as  a  stain,  the  use  of  Wright's 
blood  stain,  when  much  work  is  being  done  with  pus,  is  specially 
recommended  as  an  occasional  substitute  for  methylene  blue,  for,  if 
one  stain  is  misplaced  or  spilled,  the  worker  will  not  be  forced  to 
discontinue  the  examination.  Wright's  stain,  though  requiring 
distilled  water,  does  not  make  heat  fixation  necessary. 

Isolation  of  the  Typhoid  Bacillus. — With  our  present  knowledge 
the  practitioner  should  be  content  to  leave  this  work  to  specialists. 
At  best  it  is  tedious,  and,  when  attempted  from  suspected  water, 
is  usually  a  very  discouraging  procedure. 

Pneumonia  Versus  Tuberculosis. — "Galloping  consumption" 
may  resemble  lobar  pneumonia,  and  the  differentiation  of  these 
conditions  is  considered  under  sputum  analysis.  The  pneumo- 
coccus  is  very  small  and  is  seen  only  with  the  highest  powers. 
The  capsules  may  best  be  demonstrated  in  hanging  drop  prepa- 
rations. Cultures  are  unsatisfactory. 

Searching  fcr  the  Gonococcus. — No  cultures  should  be  at- 
tempted. Loffler's  methylene  blue  stains  well,  as  does  also  Wright's 
blood  stain.  The  typical  form  of  this  coccus,  its  occurrence  in 
pairs,  and  its  tendency  to  lie  within  the  pus  cells  are  its  character- 
istics, and  it  is  not  necessary  to  use  Gram's  stain  in  order  to  avoid 
confusion  with  other  micrococci. 

Oil  immersion  objective  should  be  used.  Three  drams  of  gin, 
taken  twelve  hours  before  the  examination,  usually  drives  this 
germ  out  of  its  hiding  places  in  the  gland  ducts. 

Searching  for  the  Colon  Bacillus. — A  germ  which,  once  con- 


SEARCHING    FOR   GERMS.  49 

sidered  harmless,  now  has  the  distinction  of  chief  etiological  factor 
in  the  following  conditions : 

1.  Some  cases  of  cystitis. 

2.  Some  cases  of  peritonitis,  especially  those  resulting  from  per- 
foration of  the  bowel  or  appendix. 

3.  Some  cases  of  appendicitis. 

4.  Some  cases  of  mucous  colitis. 

The  bacillus  coli  communis  is  a  normal  and,  doubtless,  a  neces- 
sary inhabitant  of  the  large  bowel.  Neither  the  morphological  nor 
the  cultural  properties  of  this  microorganism  are  sufficiently  char- 
acteristic to  justify  its  search.  The  presence  of  rods  in  urine  does 
not,  as  is  commonly  supposed,  warrant  the  diagnosis  of  colon 
cystitis.  For  its  relation  to  sewage  contamination  see  Some  Sim- 
ple Water  Analyses,  page  145. 

Searching  for  Molds. — There  are  three  very  common  pathogenic 
molds: 

1.  Microsppron  furfur  of  fawn  chest,  or  tinea  versicolor.    Scrap- 
ings from  the  skin  should  show,  besides  epidermal  cells,  the  hyphce 
of  this  mold,   and   intermingled   are   loose   spores  which  show  a 
tendency  to  clump  formation. 

2.  Endomyces  albicans  of  thrush;  segmented  hypha3,  with  spore 
formation  within ;  and  branchings  may  be  seen  at  segments. 

3.  Trichophyton  of  barber's  itch,  ringworm,  etc.;  a  number  of 
varieties  showing  hyphae. 

Therapeutic  indications  make  an  absolute  classification  of  these 
varieties  for  the  practitioner  unnecessary,  and  it  is  sufficient  to 
find  hyphse  or  spores,  or  both.  The  following  technic  has  given 
excellent  results : 

1.  Make  scrapings  from  the  edge  of  the  lesion,  and  never  from 
the  central  portion. 

2.  Drop  these  on  a  clean  slide,  and  add  2  or  3  drops  of  10-percent 
sodium  or  potassium  hydrate  solution. 

3.  Apply  lightly  a  clean  round  cover  glass  and  let  stand  fifteen 
minutes. 

4.  Firmly  press  down  the  cover  glass,  flattening  the  specimen. 

5.  Examine  with  a  somewhat  contracted  diaphragm  and  a  high- 
power  objective. 

Searching  for  Actinomyces. — Besides  the  ordinary  "jaw  infec- 
tions," cases  of  consumption,  ischiorectal  abscess,  and  furunculosis 
have  been  observed  in  which  the  chief  etiological  agent  seemed  to 


50  LABORATORY    METHODS. 

be  the  ray  fungus.  Cultivation  for  diagnostic  purposes  is  hardly 
worth  while.  The  characteristic  yellowish  granules  may  often  be 
observed  in  the  pus  without  the  aid  of  a  lens.  Smears  may  demon- 
strate the  characteristic  clubs;  if  they  do  not,  curettage  of  the 
walls  of  the  abscess  may  loosen  the  fungus. 

Other  Searches  Which  May  be  Attempted  by  Smears  Alone. — 
Culture  work  is  unnecessary  in  many  bacteriological  examinations. 
Many  of  these  have  been  included  in  other  chapters — viz.,  trepo- 
nema,  tubercle  bacillus,  plasmodium,  and  meningococcus.  Others 
may  be  attempted  by  the  smear  method,  as : 

1.  Spirocheta   of   Vincent's    angina;    in   certain    throat   ulcers. 

2.  Ameba  coli  and  cholera  vibrio.     (See  E very-Day  Stool  Tests, 
page  150. 

3.  Bacillus  influenza?  from  greenish  expectoration. 

4.  Bacillus  pyocyaneus  from  green  pus. 

Researches. — All  medical  truths  have  not  originated  in  medical 
schools  or  hospitals,  and  there  is  no  reason  why  a  general  practi- 
tioner should  not  have  discovered  the  treponema  pallidum  just  as 
a  country  doctor  first  identified  the  germ  of  tuberculosis.  As  an 
illustration  of  what  is  yet  to  be  discovered,  the  following  list  of 
diseases — of  an  infectious  character,  but  of  doubtful  or  unknown 
etiology — are  submitted  to  the  country  physician  for  his  consider- 
ation, of  which  diseases  the  leaders  of  scientific  research  have  thus 
far  failed  to  find  the  cause,  although  much  expense  has  been  in- 
curred by  investigations: 

1.  Infantile  paralysis. 

2.  Pellagra. 

3.  Rabies. 

4.  Acute  articular  rheumatism. 

5.  Measles. 

6.  Mumps. 

7.  Scarlet  fever. 

8.  Smallpox. 

9.  Whooping-cough. 
10.  So-called  colds. 

Difficulties  and  How  to  Avoid  Them. — Many  sources  of  error 
are  self-evident,  and  need  no  consideration,  while  some  errors  are 
made  in  following  the  various  methods.  If,  however,  the  teehnic 
of  culture  work  is  closely  followed,  there  should  be  very  little 
trouble. 


SEARCHING   FOR   GERMS.  51 

Value  and  Limitation  of  These  Searches. — Both  value  and  limi- 
tation are  variable,  not  only  as  to  the  various  microorganisms,  but 
also  as  to  the  physician — that  is,  a  procedure  which  may  be  of  value 
in  the  hands  of  one  person  will  be  a  waste  of  time  in  the  hands  of 
another.  A  physician  who  has  not  finished  a  course  in  laboratory 
bacteriology  should  be  slow  to  handle  the  more  virulent  germs,  and, 
on  the  other  hand,  the  late  graduate  may  attempt  searches  not 
recommended  in  this  book.  A  safe  rule  will  be,  before  reaching 
any  conclusion  as  to  the  identity  of  any  microorganism  or  its  re- 
lation to  the  pathological  process  at  hand,  to  thoroughly  study 
the  subject  from  the  best  works  on  bacteriology,  as  in  this  book 
only  those  examinations  have  been  selected  and  classified  which  may 
be  profitably  employed  by  the  general  practitioner. 

Searches  Left  to  Experts. — In  the  light  of  our  present  knowl- 
edge of  this  relatively  new  subject,  it  appears  that  the  practitioner 
may  wisely  avoid  working  with  some  germs,  as  follows: 

1.  Germs  identified  with  difficulty:  colon  bacillus,  typhoid  bacil- 
lus, paratyphoid  bacillus,  germs  of  food  poisonings,  dysentery  ba- 
cillus, tetanus  bacillus. 

2.  Germs  exceedingly  virulent :  plague  bacillus. 

3.  Germs  rarely  found :  anthrax  bacillus. 

Laboratory  Prophylaxis. — For  additional  information  on  this 
subject  see  Laboratory  Prophylaxis,  page  179. 


52 


LABORATORY    METHODS. 


CHAPTER  IV. 


VASCULAR  DRAMAS, 


Apparatus. 


1.  Acetic  acid,  glacial. 

2.  Acetic  acid,   1-percent. 

3.  Alcohol. 

4.  Broom  straw. 

5.  Distilled  water. 

6.  Ether. 

7.  Glycerin. 

8.  Hayem's   solution. 

9.  Horse  hairs. 

10.  Marx's  fluid. 

11.  Microscope  and   accessories. 

12.  Red  and  white  pipettes  and  count- 

ing chamber. 


13.  Slides  and  cover  glasses. 

14.  Slide  forceps. 

15.  Sodium  chlorid,  aqueous  solution, 

.85-percent. 

16.  Sticker  or  stub  pen. 
,17.  Stiff  paper. 

18.  Tallqvist  hemoglobin   chart. 

19.  Towel. 

20.  Wright's  blood  stain;    in   1-ounce 

bottles  in  liquid  form  from 
some  reliable  chemical  or  op- 
tical firm. 


The  arrangement  of  apparatus  is  shown  in  Fig.  13.  With  a 
little  practice  any  physician  may  become  expert  in  the  vari- 
ous blood  analyses.  While  some  examinations  are  of  importance, 
they  must  not  be  overestimated,  as  a  diagnostic  chain  usually  re- 
quires many  strong  links  before  it  becomes  useful  to  the  thera- 
peutist, and  only  the  few  most  valuable  procedures  are  recom- 
mended. One  method,  the  best  and  probably  the  most  simple,  is 
described  briefly,  but  no  necessary  details  are  omitted,  and  sources 
of  error  are  pointed  out  unless  self-evident.  The  actual  selection 
of  the  necessary  examinations  for  a  given  case  lies  with  the  physi- 
cian, it  being  hardly  worth  while  to  make  complete  blood  examina- 
tions in  every  case.  In  this  selection  the  diagnostician  must  not 
go  astray,  and  it  is  unwise,  for  example,  to  conclude  that,  inasmuch 
as  a  low  hemoglobin  is  observed,  the  red  count  would  be  diminished 
and  the  counting  of  the  erythrocytes  neglected. 

Development  of  the  Blood  Cells. — It  is  probable  that  all  blood 
cells,  red  or  white,  normal  or  pathological,  originate  from  one 


References. — Ewing:  Pathology  of  the  Blood;  Schleip :  Atlas  of  Hematology;  Cabot: 
The  Blood;  Da  Costa:  Clinical  Hematology;  Watkins:  Diagnosis  by  the  Blood;  all 
works  on  clinical  diagnosis,  including  Sahli,  Simon,  Boston,  Wood,  Emerson,  Webster, 
etc. 

53 


54 


LABORATORY    METHODS. 


parent  cell,  and,  with  the  exception  of  many  of  the  lymphocytes, 
all  blood  corpuscles  are  formed  in  the  red  bone  marrow.  The 
spleen,  once  termed  the  "cradle  and  the  grave"  of  the  blood,  by 
no  means  fills  either  office,  but  may  serve  often  as  a  brooder  for 
the  younger  corpuscles  and  as  a  subheart — a  "portal  pump," 


Fig.  14. — Development  of  the  blood  cells.  Schematic  representation  of  the  corpuscles 
normally  found  in  the  red  bone  marrow,  showing  how  they  give  rise  to  the  various 
circulatory  elements.  Cells  normally  present  in  bone  marrow:  1,  parent  cell;  2,  in- 
termediate forms,  with  neutrophilic,  basophilic,  and  eosinophilic  alterations;  3,  neu- 
trophilic  myelocyte;  4,  basophilic  myelocyte;  5,  eosinophilic  myelocyte;  6,  erythro- 
blast.  Cells  normally  present  in  circulation:  7,  neutrophilic  leukocyte;  8,  basophilic 
leukocyte;  9,  eosinophilic  leukocyte;  10,  lymphocyte;  11,  transitional;  12,  erythro- 
cyte;  13,  blood  plate. 

which,  by  the  slow  contractions  of  its  muscular  walls,  forces  the 
blood  through  the  liver  to  the  central  pumping  station.  Hepatic 
rather  than  splenic  tissue  forms  the  tomb  for  the  erythrocytes. 

A  modified  form  of  certain  diagrams  offered  by  Schleip,  with 
nomenclature  according  to  the  suggestion  of  Grawitz,  is  given  in 
Fig.  14. 


VASCULAR   DRAMAS.  55 

Blood  Dramas. — For  convenience  of  description,  we  may  con- 
sider each  blood  picture  a  "drama,"  the  circulatory  system  the 
"stage,"  and  the  red  bone  marrow  the  "back  of  the  scenes."  In 
the  normal  blood  picture  the  various  circulating  corpuscles  are  of 
constant  variety  and  in  practically  unvarying  number,  and  in 
differential  counts  there  are  no  marked  percentage  alterations.  In 
disease,  however,  the  scene  is  changed  and  there  is  turmoil  at  once. 
In  these  conflicts  certain  types  may  be  deformed  or  destroyed, 
others  may  be  increased  in  number,  and  finally,  in  the  so-called 
crises,  those  cells  not  ordinarily  observed  in  the  circulating  fluid 
may  be  called  from  the  home  or  the  brooder  to  aid  their  struggling 
offspring.  It  must,  therefore,  be  concluded  that  the  so-called  blood 
diseases  do  not  give  rise  to  corpuscles  hitherto  not  found  in  the 
circulating  blood  or  in  the  blood-forming  organs.  Every  morbid 
blood  scene  has,  for  its  characters,  dead,  dying,  or  wounded  normal 
cells  along  with  certain  other  varieties  in  increased  numbers — 
active  or  injured  maternal  reinforcements.  By  keeping  these 
points  in  mind,  the  significance  of  each  blood  smear  can  be  realized 
without  difficulty,  and  the  pathology  of  blood  diseases  will  be  easily 
comprehended  by  the  clinician. 

Behind  the  Scenes. — Here  is  the  busy  spot.  For  example,  in 
pernicious  anemia,  as  the  red  cells  are  destroyed,  there  is  call  for 
reinforcements.  The  organism  demands  even  more  oxygen  than 
usual,  and  an  extra  strain  is  put  on  the  bone  marrow.  More  and 
more  red  cells  are  rushed  into  the  circulation,  but  to  no  avail. 
Finally  the  bone  marrow  becomes  fatigued — if  we  may  use  such 
term — as  those  storehouses  in  the  spleen,  hemolymph  glands,  and 
perhaps  other  organs  and  tissues  have  been  exhausted,  and  the 
demand  exceeds  the  supply.  The  result  is  an  inferior  product, 
or,  to  adhere  more  closely  to  our  comparison,  "understudies." 
Cells,  hardly  fitted  for  the  assumption  of  the  duties  thrust  upon 
them,  are  rushed  to  the  fray.  Among  these  are  found  the  over- 
sized and  undersized  cells,  forms  showing  mitoses  and  red  cells 
which  have  not  yet  cast  aside  their  nuclei.  They  are  quickly 
destroyed,  and  their  dying  forms — polychromophilia,  poikiloblasts, 
etc. — must  not  be  mistaken  for  cells  entirely  foreign  to  the  organ- 
ism. Then  the  bone  marrow  rouses  and  concentrates  its  energies 
in  one  mighty  effort ;  there  results  the  blood  crisis,  the  sending  out 
of  certain  forms  not  only  unfitted  by  improper  development  for 
the  struggle,  but  often  already  diseased — the  megaloblasts.  In 


56  LABORATORY    METHODS. 

this  manner  a  little  study  may  make  plain  the  picture  or  scenes  of 
any  blood  disease. 

Cast. — The  complete  description  of  blood  corpuscles  will  be 
found  in  the  larger  books,  but  a  few  brief  hints  may  not  be  amiss. 
In  all  cases  where  the  colors  of  stained  preparations  are  considered 
it  is  to  be  understood  that  reference  is  made  to  Wright's  stain. 
Although  blood  cells  appear  flat  when  spread,  fixed,  and  stained, 
such  is  not  their  appearance  in  the  natural  state.  All  white  cells 
are  globular,  the  polymorphonuclear  forms  showing  pseudopods. 
The  red  cell  is  not  a  biconcave  disk,  as  was  the  former  conception, 
but  is  thimble-shaped — i.  e.,  one  surface  is  very  convex  and  the 
other  deeply  concave,  such  morphology  being  a  direct  result  of  the 
extrusion  of  the  nucleus  of  the  erythroblast.  These  nuclei,  in  turn, 
are  supposed  to  give  rise  to  the  blood  platelets. 

For  convenience,  the  blood  corpuscles  have  been  arranged  in  sys- 
tematic order,  and  only  those  characteristics  observed  in  the  stained 
preparation  are  considered : 

Red  Cells.— 

1.  Erythrocyte;  the  normal  red  cell;  orange  or  pink. 

2.  Undersized  cell ;  sometimes  normal. 

3.  Microcyte;  very  small  erythrocyte;  invariably  pathological. 

4.  Oversized  cell ;  sometimes  normal ;  in  large  numbers  are  char- 
acteristic of  pernicious  anemia. 

5.  Macrocyte  or  megalocyte ;  very  large  red  cell ;  this  and  re- 
maining forms  of  red  cells  are  always  pathological. 

6.  Poikilocyte ;  irregular  form,  with  beak  or  snout. 

7.  Shadow  or  ghost ;  loss  of  hemoglobin,  with  distended  cell  wall. 

8.  Endoglobular  degenerations;   appear  as  unstained  droplets 
within  the  protoplasm. 

9.  Enlarged  delta. 

10.  Small  delta. 

11.  Normoblast;  with  single  deep-blue  nucleus. 

12.  Microblast;  small  normoblast. 

13.  Macroblast  or  megaloblast ;  macrocyte,  with  pale  nucleus  and 
signs  of  degeneration. 

14.  Poikiloblasts ;  nucleated  poikilocytes. 

15.  Degenerating  normoblasts ;  showing  lobulated  nuclei. 

16.  Forms    showing    karyorrhexis ;    granular    disintegration    of 
nuclei. 

17.  Forms  showing  karyokinesis ;  division  figures  in  nuclei. 


VASCULAR   DRAMAS. 


57 


18.  Polychromatophilia  or  paradoxical  stain ;  where  nuclear  dust 
of  karyorrhexis  mixes  with  hemoglobin,  causing  a  bluish  tint. 

White  Cells. — Percentage  refers  to  the  differential  count  in 
adult's  blood. 

1.  Lymphocyte  (19  percent)  ;  robin 's-egg-blue  cytoplasm;  round 
purple  nucleus. 

2.  Transitional    (3    percent);    light-blue    cytoplasm;    horseshoe 
nucleus. 

3.  Polymorphonuclear  eosinophile    (2  percent)  ;  cytoplasm  con- 
tains large  and  deep-red  granules ;  lobulated  nucleus. 

4.  Polymorphonuclear  basophile  (1  percent)  ;  cytoplasm  contains 
medium-sized,  light-blue  granules ;  lobulated  nucleus. 

5.  Polymorphonuclear  neutrophile  (75  percent)  ;  cytoplasm  con- 
tains small  reddish-lilac  granules ;  lobulated  nucleus. 

6.  Myelocytes  containing  the  various  colored  granules;  these  are 
very  large  cells,  with  single  nuclei ;  pathological. 

7.  Degenerating  leukocytes;  cytoplasm  contains  vacuoles;  patho- 
logical. '  ^ '. 

8.  Disintegrating  leukocytes;  disappearance  of  cytoplasm,  with 
a  scattering  of  the  granules ;  pathological. 

9.  Necrotic  changes;  nuclei  stain  poorly  or  not  at  all,  or  else 
show  fragmentation. 

Blood  Dramas. — The  table  given  on  page  58  serves  to  differen- 
tiate the  more  common  blood  conditions.  For  detailed  information 
reference  should  be  made  to  the  larger  books. 

Bedside  Apparatus.  In  case  the  patient  is  bedfast,  suitable 
specimens  of  the  blood  may  be  obtained  and  taken  to  the  office  for 
examination.  Dilutions  and  spreads  may  be  completed  with  little 
apparatus,  which  may  be  easily  carried  in  the  physician's  hand- 
bag, as: 


1.  Towel. 

2.  Blood  sticker  or  stub  pen. 

3.  Hemoglobin  chart. 

4.  Red  and  white  pipettes. 

5.  Catheter  tubing. 

6.  Vial    containing   Hayem's   solution 

for  reds. 


7.  Vial  containing    (1-percent)    acetic 

acid  for  whites. 

8.  Vial  containing  alcohol. 

9.  Six    clean    slides    and    some    stiff 

wrapping  paper. 


The  towel  should  be  clean,  and  a  clean  towel  or  handkerchief 
can  usually  be  obtained  at  the  home  of  the  patient.  A  nickel- 
plated  German  blood  sticker  offers  no  advantage  over  a  stub  pen 


58 


LABORATORY   METHODS. 


with  one  point  broken  off.  Arneill  recommends  small  rubber 
catheters  instead  of  the  tubing  supplied  with  blood  pipettes,  and, 
if  these  are  sufficiently  long,  the  free  end  may  be  brought  around 
ana  slipped  over  the  point,  in  which  condition  the  diluted  and 
prepared  blood  may  be  transferred  to  the  office  and  examined  ;it 
leisure.  A  blood  spread  which  has  dried  may  be  wrapped  in  heavy 
paper  and  taken  to  the  office. 

THE   MORE    COMMON   BLOOD   CONDITIONS.1 


Disease 
or 
condition 

Red 

cells 

Hemo- 
globin 

White 
cells 

Cytology 

Chlorosis 

N 

— 

N 

Polycythemia 

+ 

Xor  + 

N 

Secondary  ane 

mia 





Nor  — 

(a)     Post-hemorrhagic  —  undersized    red    cells, 

few    poikiloeytes,     some     endoglobular     de- 

generation, normoblasts.      (b)     Cachectic  or 

toxic  —  microcytes,    undersized    cells,    more 

Pernicious  or 

poikiloeytes,     more     degeneration;     normal 

large-celled 

and  degenerating  normoblasts. 

anemia 



— 

— 

Loss  of  hemoglobin  greater  than  above,  mod- 

erate  degeneration,    oversized   cells,    macro- 

cytes,  megaloblasts,  polychromatophilia,  mi 

toses,    degenerating    normoblasts,    less    poi- 

kilocytosis  than  above. 

Leukopenia 

Xor  — 

N  or  — 

— 

A   condition   in   typhoid,   acute  miliary  tuber- 

culosis     and      pernicious      anemia;      white 

count   decreased   due   mainly   to   diminution 

in     the     polyinorphonuclears;     lymphocytes 

are  .increased. 

Leukocytosis 

N  or  — 

Xor  — 

+ 

Xoted   in  purulent   infections;    polymorphonu- 

clears  actually  increased;  lymphocytes  rela- 

tively,  but  not  actually,   diminished. 

Leukemia 

— 

— 

+ 

(a)    Lymphatic  —  increase  of  the  lymphocytes. 

(b)      Myelogeuous  —  increase    of    the    poly- 

inorphonuclears,   appearance    of    myelocytes 

in  the  blood. 

Eosinophilia 

— 

•  —  • 

+ 

Increase   of   eosinophilic  polymorphonuclears; 

noted    in    trichinosis,    asthma,    uncinnriasis, 

menstruation,    positive    tuberculin,    certain 

Hodgkin's  dis- 

skin diseases,  etc. 

ease 
I.ymphosarco- 

"7 

~~ 

Picture  of  a  cachectic  secondary  anemia. 

ma 

— 

— 

+ 

Large     cells    or    cells    of    various    sizes,    re- 

sembling   very    much    the    lymphocyte,    but 

lodophilia 

N 

X 

+ 

staining    poorly    or    showing    degenerations. 
Certain    iodin    reaction    seen    in    the    polymor- 

phonuclears   when    purulent    processes    are 

present   in    the   body. 

Obtaining  the  Blood. — Although  the  lobe  of  the  ear  furnishes 
blood  in  considerable  quantity,  it  may  be  often  necessary  in  bed- 
fast patients  to  use  the  finger  tip.  A  cold,  bloodless  integument 
does  not  represent  that  actual  blood  picture  which  may  be  present 
at  other  parts.  If,  however,  a  massage  is  undertaken,  it  is  best  to 


'  X,    normal:    -j~.    increased;    — ,    diminished. 


VASCULAR   DRAMAS.  59 

wait  until  the  deep-red  color  is  replaced  by  the  normal  tint.  The 
puncture  should  be  made  quickly,  and  should  be  fairly  deep,  so 
that  repetition  will  not  be  necessary. 

Macroscopical  Examination. — Except  in  aggravated  conditions, 
such  an  examination  is  of  little  use  in  diagnosis.  A  mushy  blood 
may  be  due  to  a  severe  leukemia,  a  "whey"  solution  may  suggest 
a  great  decrease  in  the  number  of  cells,  a  pale  blood  signifies  hemo- 
globinemia,  and  chocolate  or  crimson  tints  may  be  due  to  certain 
poisons.  Without  a  suitable  chart,  colors  are  often  misleading,  and 
the  laity  watch  with  interest  the  changes  in  the  color  of  the  blood 
when  in  reality  tests  would  show  that  there  is  no  alteration  in  the 
hemoglobin. 

Microscopical  Examination  of  Fresh  Blood. — Experts  are  often 
able  to  pass  a  final  conclusion  from  a  mere  inspection  of  a  hanging 
drop.  Although  the  practitioner  may  make  certain  interesting 
observations,  no  final  diagnostic  inferences  should  be  drawn  from 
this  procedure,  and,  if  time  is  of  importance,  he  may  well  omit  this 
examination. 

Hemoglobin  Estimation.— For  practical  purposes,  the  Tallqvist 
color  chart  is  sufficient.  The  original  booklet  form  has  a  decided 
advantage  over  its  modifications,  as  it  is  convenient  to  carry  and  is 
not  easily  soiled.  Instructions  accompany  each  booklet.  The 
comparison  of  the  color  of  the  droplet  with  that  of  the  chart  should 
be  made  at  once,  as  certain  changes  take  place,  on  drying,  in  the 
hemoglobin.  In  case  the  physician  has  no  hemoglobin  chart  with 
him,  he  will  not  be  entirely  at  a  loss,  as  comparison  of  a  drop  of  the 
patient 's  blood  with  his  own  on  a  piece  of  white  blotting  paper  may 
bring  out  good  color  distinctions. 

Suspension  of  Red  Cells. — Blood,  after  coagulating  in  pipettes, 
gives  considerable  trouble,  and  the  beginner  may  find  it  advan- 
tageous to  practice  with  a  little  carmine  water.  Dilutions  must  be 
made  quickly.  Wipe  away  any  blood  which  may  be  present  at  the 
puncture,  and,  when  the*  next  drop  appears,  immerse  well  the 
point  of  the  red  pipette  below  its  surface  and  draw,  by  mouth 
suction,  a  solid  column  of  the  blood  to  the  mark  0.5.  Quickly 
wipe  off  the  point  and  instantly  immerse  it  into  the  vial  of  Hayem's 
solution.  Now  quickly  draw  up  this  fluid  until  the  mixture  reaches 
101.  While  this  is  being  done  the  pipette  should  be  twirled  be- 
tween the  fingers,  thereby  insuring  a  thorough  mixing  of  the  liquid. 
Stop  suction  and  remove  rubber  tube.  With  a  thumb  closing  one 


60  LABORATORY   METHODS. 

end  and  the  middle  finger  closing  the  other,  shake  well.  The  dilu- 
tion is  complete,  and  the  free  end  of  the  catheter  may  be  pulled 
over  the  point,  as  suggested  above.  After  reaching  the  office, 
another  shaking  is  advisable,  as  the  cells  show  a  tendency  to  settle 
to  the  more  dependent  portions.  Some  persons  prefer  to  remove 
the  tubing  entirely  before  leaving  the  home  of  the  patient,  and  slip 
around  the  ends  of  the  pipette  a  wide  rubber  band,  which  serves 
to  prevent  any  leakage. 

Errors  and  Difficulties. — Solid  columns  of  liquid  are  imperative. 
Air  segments  occur  when  the  drop  is  too  small  or  when  the  point 
of  the  pipette  has  not  been  sufficiently  immersed.  It  may  be  impos- 
sible to  draw  any  fluid  into  the  tube,  which  indicates  a  plugged 
pipette,  due  either  to  an  old  clot  or  a  piece  of  dirt,  which  may  be 
seen  by  the  use  of  a  hand  lens  or  with  the  naked  eye.  A  little 
glacial  acetic  acid  and  a  horse  hair  may  •  establish  a  lumen,  and, 
in  case  these  fail,  a  fine  hypodermic  needle  may  be  used,  but  care 
must  be  exercised  that  the  point  of  the  pipette  is  not  broken  off. 
The  same  methods  may  be  employed  when  a  column  of  the  blood 
has  coagulated  in  the  tube.  In  case  the  initial  blood  column  passes 
the  proper  marking,  a  towel  touched  quickly,  but  skillfully,  to  the 
point  may  take  up  the  excess  of  blood  and  bring  the  top  of  the 
column  down  to  the  proper  mark. 

Red  Count. — After  discarding  four  drops  of  the  diluted  blood, 
one  small  drop  is  blown  into  the  clean  counting  chamber  and  the 
cover  glass  applied.  The  contact,  of  the  glass  surfaces  must  be 
perfect,  and  this  is  shown  by  Newton's  rings — a  play  of  rainbow 
colors — seen  best  from  an  almost  horizontal  reflection  of  light.  If 
the  drop  is  too  large,  it  spills  out  of  the  well  and  prevents  the 
appearance  of  the  rings.  In  such  case  the  rings  may  be  brought 
out  by  pressure  on  the  cover  glass,  but  will  disappear  if  the  pres- 
sure be  removed.  Permit  the  preparation  to  stand  undisturbed 
for  five  minutes,  so  that  the  corpuscles  may  settle  into  the  pens. 

There  is  practically  no  difference  in  the  various  rulings  so  far  as 
the  inner  counting  pens  are  concerned.  Butler  proposes  that 
when  the  lines  become  faint  they  may  be  rendered  very  distinct  by 
scraping  off  some  graphite  from  a  soft  lead  pencil,  rubbing  the 
powder  over  the  surface  of  the  disk,  and  then  polishing  it  off  with 
a  soft  handkerchief. 

The  authors  have  tried  with  varying  success  at  least  half  a  dozen 
methods  of  counting  red  blood  cells,  but  feel  that  still  another 


VASCULAR   DRAMAS. 


61 


method  must  be  offered  to  the  person  who,  although  desiring  the 
best  results,  must,  for  the  sake  of  his  patient,  proceed  with  more 
haste  than  is  usually  required  of  many  laboratory  workers.  The 
technic  of  this  other  method  consists  of  a  combination  of  several 
methods,  and  possesses  the  following  advantages : 

1.  Simplicity. 

2.  By  avoiding  the  square  field  methods,  it  obtains  more  nearly 
an  average  of  the  entire  dilution.     The  most  careful  workers  too 
often  complain  that  the  count  in  one  area  often  varies  exceedingly 
with  other  counts,  and  consequently  many  fields  must  be  counted 
in  order  to  find — what  is,  after  all,  the  main  result  desired — an 
average. 

3.  Prevents  "losing  the  place." 


7 


8 


M 


Fig.  15. — Scheme  for  rapid'counting  of  red  cells. 

SIMPLE  METHOD.  Only  four  careful  counts  are  made,  and  each 
of  these  includes  ten  squares,  or  forty  in  all.  This  may  seem  too 
few,  but,  if  each  of  the  four  counts  is  made  in  a  different  portion 
of  the  preparation,  there  will  be  greater  probability  of  striking  an 
average  than  where  several  square  areas  are  counted  and  the  fact 
overlooked  that,  in  spite  of  the  best  efforts,  the  cells  lie  more 
closely  together  in  one  area  than  in  another. 

All  corpuscles  on  the  heavy  lines  and  within  the  shaded  areas  are 
counted  (Fig.  15).  The  beginning  position  is  self-evident,  and 
may  be  any  one  of  a  number  of  points,  the  new  Turck  ruling  giving 
a  choice  of  one  hundred  and  forty-four  such  counts.  This  method 
guards  against  "losing  the  place,"  a  complaint  that  is  old  and  well 


62  LABORATORY    METHODS. 

founded.  By  using  the  proper  ocular  and  drawing  high  the  tube 
of  the  microscope,  the  field  may  be  greatly  magnified.  Always  use 
a  low-power  objective  and  narrow  the  diaphragm.  In  normal  blood 
each  of  the  little  squares  should  average  about  6.2  cells,  which 
number  is  increased  in  polycythemia  and  decreased  in  anemia.  An 
estimate  of  the  number  of  red  cells  in  each  cubic  millimeter  of 
capillary  blood  should  be  made,  and  this  computation,  for  diagnostic 
purposes,  need  not  be  accurate,  but,  while  watching  the  progress 
of  a  blood  disease,  considerable  care  must  be  taken.  Add  the  four 
countings,  multiply  by  2,  and  add  four  ciphers  to  the  product. 
For  example,  suppose  the  four  counts  were  respectively  60,  59,  57, 
and  60.  The  sum  of  these  would  be  236 ;  multiplying  by  2  gives  a 
product  of  472;  adding  the  ciphers,  we  have  4,720,000  cells  for 
each  cubic  millimeter.  This  should  be  done  in  a  very  few  minutes, 
and,  it  is  safe  to  say,  no  better  average  of  the  entire  ruled  disk 
could  be  taken. 

Cleaning  Pipettes. — This  should  be  done  as  soon  as  the  count  is 
finished,  and  the  following  method  gives  the  best  results : 

1.  Attach  rubber  tubing  to  the  pointed  end  of  the  pipette,  re- 
moving it  from  the  other  end. 

2.  Remove    the    remainder    of   the    blood    solution   by    blowing 
through  the  rubber  tubing. 

3.  Immerse  the  large  end  of  the  pipette  in  dilute  acetic  acid, 
suck  the  liquid  into  the  pipette,  and  blow  it  out,  repeating  the 
procedure  with  absolute  alcohol. 

4.  Suck  some  ether  into  the  pipette. 

5.  Remove  rubber  tube  and  hold  pipette  firmly  in  hand. 

6.  Because  of  the  moisture  ordinarily  present  in  the  exhaled  air, 
ether  can  not  be  expelled  by  blowing,  but  by  swift  downward  jerks 
of  the  hand. 

Only  in  case  the 'glass  mixing  ball  shows  no  tendency  to  adhere 
to  the  inner  surface  of  the  pipette,  can  the  latter  be  placed  away 
as  clean.  It  may  be  necessary,  if  blood  is  still  present,  to  repeat 
the  entire  technic,  but,  if  only  moisture  interferes,  the  acetic  acid 
wash  may  be  omitted.  Stronger  acids,  horse  hairs,  or  even  fine 
needles  may  be  employed  to  remove  the  more  obstinate  clots. 

White  Count. — Various  bedside  technics,  where  a  hand  lens  is 
used,  have  been  devised.  They  may  serve  some  persons  well,  and 
should  not  be  condemned,  but  the  authors  adhere  to  the  use  of  the 
microscope  for  the  following  reasons : 


VASCULAR   DRAMAS. 


63 


1.  The  older  methods  are  simple,  and  white  counting  does  not 
usually  require  haste,  except  possibly  in  infectious  cases. 

2.  More  accurate  results  are  obtained  when  privacy  is  secured 
and  a  microscope  is  used.     Correct  counts  are  not  easily  obtained 
in  the  environment  of  the  sick-room. 

3.  The  microscope  always  distinguishes  between  cells  and  dirt, 
and  also  between  red  cells  and  white  cells. 

It  will,  therefore,  be  seen  that  the  rough  methods  of  counting 
white  cells  are  subject  to  serious  limitations.     The  special  white 


•  Pig.  16. — Spreading.      After  the  blood  has  run  along  the  edge  of  the  spreader,  the  drop  is 
pushed  over  the  surface  of  the  other  slide. 

cell  pipette  and' 1-percent  acetic  acid  as  a  diluent  are  used,  the 
technic  being  identical  with  that  described  for  the  red  cells.  The 
acetic  acid  destroys  the  hemoglobin,  so  that  only  the  white  cells 
may  be  seen,  and  brings  out  the  nuclei  of  the  white  cells.  Much 
yellow  sediment  indicates  that  the  acid  is  not  strong  enough.  It 
is  often  necessary  to  filter  the  acid  solution  at  intervals  of  several 
months. 

Draw   up    the   microscope    tube    to    such    a    distance    that   the 
periphery  of  its  field  cuts  exactly  the  corners  of  the  large  square 


64 


LABORATORY   METHODS. 


millimeter,  and  permit  the  tube  to  remain  in  this  position.  In 
different  portions  of  the  preparation  take  five  counts,  including  in 
each  of  these  every  white  cell  in  the  field.  The  sum  of  the  five 
fields  divided  by  2,  and  with  two  ciphers  added  to  this  quotient 
gives  the  number  of  leukocytes  in  each  cubic  millimeter  of  blood.1 
For  example,  suppose  that  the  counts  are  29,  35,  35,  32,  and  35, 
their  sum  would  be  166;  this  divided  by  2  gives  83;  adding  two 
ciphers  gives  8,300.  This  rapid  method  was  proposed  by  F.  J. 
Wright,  of  the  Calumet  and  Hecla  Hospital,  Michigan. 

Making  the  Spread. — The  most  satisfactory  method  of  prepar- 
ing blood  films  is  that  in  which  the  slides,  rather  than  cover  glasses, 


E 


G 


IT 


Fig.  17. — Artifacts  in  blood  films.  A,  pressure  forms;  B,  elongations;  C,  poor  fixation; 
D,  dirt;  E,  normal  stain;  F,  understating;  G,  overstaining;  H,  crenated  cell;  I, 
ghost  or  shadow. 

"*-•' 

are  used.    The  following  technic  takes  the  preparation  to  the  stain- 
ing: 

1.  Touch  the  edge  of  an  end  of  a  clean  slide  to  a  blood  drop  and 
transfer  it  to  the  face  of  another  slide  near  its  end. 

2.  When  the  drop  spreads  along  the  edge  of  the  smearer,  push  it 
over  the  face  of  the  second  slide  (Fig.  16). 

3.  Dry  in  air. 

4.  Wrap  in  stiff  paper  and  carry  to  the  office  for  staining.     If 
left  exposed  to  flies,  they  will  rapidly  eat  off  the  corpuscles. 

5.  No  fixation  is  necessary  when  using  Wright's  stain. 
Artifacts  in  Erythrocytes. —  (Fig.   17.)     Where  fields  are  too 


1  A  dilution  of  1 :40  is  necessary.  This  proposition  has  reference  to  the  large  form 
of  the  white  blood  counter,  which  has  a  capacity  of  21.  In  case,  however,  the  small 
form  of  the  white  pipette  is  used,  which  has  a  capacity  of  11,  corrections  must  be 
made  accordingly,  but  the  former  pipette  is  recommended  as  being  more  convenient. 


VASCULAR  DRAMAS.  65 

crowded,  certain  irregular  pressure  forms  may  suggest  poikilo 
cytosis.  Parallel  elongations  of  cells  are  due  to  pulling  them  out 
while  making  the  smear.  Bean-shaped  forms  are  a  direct  result 
of  poor  fixation.  A  piece  of  dirt — usually  black,  rather  than  blue 
— may,  by  virtue  of  its  position  on  an  erythrocyte,  suggest  a  normo- 
blast.  Endoglobular  degeneration  is  made  evident  by  the  tendency 
of  certain  erythrocytes  to  take  the  stain  rather  poorly.  If,  how- 
ever, all  the  red  cells  appear  pale,  there  is  sufficient  reason  to  con- 
clude that  the  preparation  has  been  understained.  In  case  over- 
staining  takes  place,  the  delta  may  not  be  easily  recognized. 

Staining  the  Blood  Film. — The  Wright's  stain  is  simple,  its  use 
rapid,  and  its  action  all  that  can  be  desired.  A  little  practice  is, 
however,  necessary,  and  the  following  technic  will  give  the  best 
results : 

1.  Cover  the  film  with  a  noted  quantity  of  the  staining  fluid 
dropped  quickly  from  a  pipette  or  medicine  dropper. 

2.  After  two  minutes  add  to  the  staining  fluid  on  the  film  the 
same  quantity  of  distilled  water  with  the  medicine  dropper,  and 
allow  the  mixture  to  remain  exactly  two  and  one-half  minutes.     If 
the  stain  is  all  right,  this  should  give  an  intense  coloration  to  the 
cells.     A  longer  period  of  staining  invariably  produces  a  precipi- 
tate.    Eosinophilic   granules   are   best  brought   out  by   a  shorter 
period  of  staining.     The  quantity  of  the   diluted   liquid   on   the 
preparation  should  not  be  so  large  that  some  of  it  runs  off.     The 
water  may  show  a  tendency  to  gather  in  drops  and  roll  off  the 
stain,  so  that  it  may  be  necessary  to  mix  it  thoroughly  with  the 
latter  before  all  is  added.     An  ordinary  medicine  dropper  full  of 
the  stain  and  the  same  amount  of  the  water  are  usually  sufficient. 

3.  Pour  off  the  liquid  and  wrash  the  preparation  in  ordinary 
water  for  thirty  seconds,  or  at  least  until  all  precipitated  stain  is 
washed  away  and  the  preparation  assumes  a  pink  color. 

4.  Dry  between  blotters. 

5.  In  several  places,  as  may  seem  advisable,  add  cover  glasses  by 
means  of  balsam.     If  square  or  oblong  cover  slips  are  used,  prac- 
tically all  of  the  preparation  may  be  covered. 

Authors'  Slide  Forceps. — Any  one  who  has  worked  with  the  slide 
smear  in  preference  to  the  cover  glass  preparation  has  been  at  a 
disadvantage  in  staining,  as  the  Novy  locking  forceps,  as  well  as  the 
other  varieties,  can  not  be  used  with  the  ordinary  slide.  The 
authors  have  devised  locking  forceps  which  are  sufficiently  power- 


66 


LABORATORY    METHODS. 


ful  to  render  the  drop  staining  method  applicable  to  slide  spreads. 
In  the  illustration  (Fig.  18)  a  regular  hemostatic  forceps  has  been 
used,  and  the  bends  not  only  permit  point  coaptation,  but  uiiaid 
against  crushing  the  slide. 

Examination  of  Spreads. — This  consists  of  a  study  of  a  stained 
smear  under  low  and  high  power,  .  especially  under  the  latter. 
Proper  diagnoses  may  be  made  by  reference  to  the  table  on  com- 
mon'blood  conditions  (page  58).  For  a  description  of  the  stain- 
ing properties  of  the  corpuscles  see  page  56. 


Fig.  18. — Authors'  slide  forceps.      A,  Pean's  hemostatic  forceps:  B.  shows  alteration;  X, 
prevents  crushing  of  the  slide  when  locking;  Z,  permits  point  coaptation. 

Differential  Leukocyte  Count.: — Certain  diagnostic  and  prog- 
nostic data  may  be  obtained  from  the  determination  of  the  per- 
centage of  the  various  types  of  white  blood  cells  which  may  be 
present — an  absolute  increase  in  the  polymorphonuclears  being 
termed  a  leukocytosis,  a  decrease  being  termed  a  leukopenia,  etc., 
each  of  the  varied  pictures  representing  some  fact  of  clinical  im- 
portance. 

For  this  work  a  mechanical  stage  is  an  aid,  but  not  a  necessity, 


VASCULAR   DRAMAS.  67 

the  latter  statement  being  a  direct  contradiction  of  that  usually 
made  in  text  books.  At  least  300  white  cells  should  be  classified 
unless  the  probable  condition  is  self-evident.  The  computation  is 
easily  made.  For  example,  if  255  of  these  300  cells  were  lympho- 
cytes, it  follows  that  these  constitute  85  percent  of  the  entire  white 
count — probably  a  lymphatic  leukemia,  etc.  Whether  a  mechan- 
ical stage  is  or  is  not  employed,  the  worker  must  never  attempt  to 
encroach  upon  a  field  whose  cells  have  been  previously  numbered. 

Parasites  and  Microorganisms. — The  presence  of  the  plasmo- 
dium  is  easily  demonstrated  by  Wright's  stain,  which  offers  not 
only  the  most  simple  procedure,  but  brings  out  the  most  beautiful 
color  contrasts.  The  body  of  the  parasite  stains  blue,  while  the 
chromatin  varies  from  lilac  to  red,  or  almost  black.  The  chief 
source  of  error  is  mistaking  blood  platelets  for  endoglobular  forms 
of  the  plasmodium,  as  the  former  often  lie  upon  or  even  within  the 
red  cell,  but  are  of  a  homogeneous  blue  color.  The  plasmodium, 
when  really  seen,  is  rarely  mistaken  for  anything  else.  It  is  not 
the  purpose  of  this  book  to  enter  into  a  discussion  of  the  morphol- 
ogy of  this  microorganism. 

To  Prove  Presence  of  Blood. — Take  a  stain. 

1.  Place  some  of  the  stain  on  a  glass  slide. 

2.  Add  1  drop  of  very  dilute  (.85-percent)  salt  solution. 

3.  Evaporate  very  slowly  at  a  low  temperature. 

4.  Add  4  drops  of  glacial  acetic  acid. 

5.  Apply  a  clean  cover  glass. 

6.  Again  evaporate  very  slowly   at  a  low  -temperature;   fluid 
should  steam,  but  not  boil. 

7.  Add,  twice,  3  drops  of  glacial  acetic  acid,  and  evaporate  each 
time. 

8.  Cool. 

9.  Elevate  cover  glass  and  add  1  drop  of  glycerin. 
10.  Examine. 

Blood,  if  present,  is  shown  by  the  presence  of  dark-brown  rhom- 
boid crystals,  which  may  vary  in  size,  and  there  will  be  a  tendency 
of  these  crystals  to  rosette  formation.  This  is  called  the  hemin 
test, 

To  Differentiate  Fowl's  from  Mammal's  Blood. — Take  a  blood 
clot.  Tease  out  some  of  the  clot  in  Marx's  fluid  and  examine  under 
the  microscope.  Marx 's  fluid  is  made  up  as  follows : 


68  LABORATORY    METHODS. 

R    Quinin    hydrochlorate,    1 :  1,000 2  drams. 

Potassium   hydrate   solution,   33-percent 2  drains. 

Eosin,   yellow    about  5  drops. 

Misce. 

Red  cells  should  be  stained  pink.  Those  of  the  mammal  appear 
as  unnucleated  circular  disks,  but  those  of  birds  and  reptiles  are 
oval  and  nucleated. 

To  Prove  Human  Blood. — This  can  be  done  only  by  the  pre- 
cipitin  test,  a  difficult  procedure,  calling  for  expert  assistance. 

Determination  of  Coagulation  Time. — This  may  be  roughly 
computed  as  follows: 

1.  Allow  several  drops  of  fresh  blood  to  fall  on  a  clean  ^1,-iss 
slide. 

2.  At  intervals  of  a  minute  make  tests  by  drawing  a  smooth 
white  broom  straw  lightly  through  each  drop. 

3.  The  coagulation  time  is  reached  when  threads  of  fibrin  tend 
to  cling  to  the  straw.     The  average  coagulation  time  is  about  five 
minutes,  and  when  it  reaches  or  exceeds  ten  minutes  it  may  be 
considered   pathological,   and  operative  procedures  should  be  at- 
tempted with  caution.     In  jaundice  and  hemophilia  this  time  is 
greatly  increased.     The  coagulation  time  may  be  experimentally 
or  therapeutically  shortened  by  the  administration  of  gelatin  or  the 
calcium  salts. 

Widal  Test. — This  is  described  in  Diazo  Versus  Widal,  page  104. 

Diagnosis  of  Carbon  Monoxid  Poisoning. — Treat  the  sample  of 
blood  with  twice  its  volume  of  1.3  specific  gravity  solution  of  caustic 
soda.  Normal  blood  is  changed  to  a  dirty-brown,  but,  if  carbon 
monoxid  is  present,  a  beautiful  cherry-red  will  be  seen. 

Tests  Seldom  or  Never  Attempted  by  the  Practitioner. — 

1.  Opsonic  work. 

2.  Wassermann  reaction  and  its  modifications. 

3.  Detection  of  iodophilia. 

4.  Searches  for  tropical  microorganisms. 

5.  Blood  cultures;  searching  for  microorganisms  in  the  blood 
other  than  the  plasmodium. 

6.  Diabetes  tests. 

7.  Medico-legal  work. 

Value  and  Limitation  of  These  Tests. — A  correct  interpretation 
of  these  tests,  with  a  more  or  less  complete  application  of  the  va- 
rious procedures,  will  prove  of  inestimable  value  in  many  diagnos- 


VASCULAR   DRAMAS.  69 

tic  and  prognostic  difficulties.  A  "blood  analysis"  should  not, 
however,  be  overestimated,  as  a  blood  picture  may  be  ever  so  beau- 
tiful and  characteristic,  teeming  with  symptomatic  therapeutic 
indications,  and  notwithstanding  this  appearance  fail  to  indicate 
the  chief  etiological  factor.  It  is  often  only  by  a  series  of  exam- 
inations that  the  case  in  question  may  receive  a  rational,  scientific 
treatment. 


70 


LABORATORY    METHODS. 


CHAPTER  V. 


CHEMISTRY  AND  BIOLOGY  OF  THE  GASTRIC  JUICE. 

Apparatus. — Analysis  of  the  gastric  contents  shows  but  few 
things  of  value  to'  the  clinician  or  the  general  practitioner,  but 
these  are  very  important  in  making  a  correct  diagnosis  of  a  stom- 
ach disease.  In  order  to  make  these  tests  with  ease  and  accuracy, 
only  a  few  special  pieces  of  apparatus  and  a  few  reagents  are  nec- 
essary : 


1.  Buret,    graduated    to    50    cc.,    with 

stop-cook  or  pineb-cock. 

2.  Sodium    hydrate,    1  /.  „    normal.     In 

order  to  obtain  dependable  re- 
sults, this  solution  must  be  ac- 
curate. Prepared  quantitative 
solutions  are  obtainable  from 
reputable  chemical  firms,  or  may 
be  prepared  by  an  expert  phar- 
macist. 

3.  Dimethylamidoazobenzol,     a     weak 

aqueous  solution. 


4.  Phenolphthalein,    a    1 -percent    al- 

coholic solution.. 

5.  Gunx.burg's  reagent. 
G.  Ferric  chlorid. 

7.  Stomach  tube  with  bulb. 

8.  Evaporating  dish. 

9.  Delicately    graduated    pipette,    10 

cc. 

1 0.  Slides  and  cover  glasses. 

11.  Microscope  and  accessories. 


Contraindications  for  Stomach  Washing.— 

1.  Recent  hemorrhage  from  the  stomach. 

2.  Diseased  esophagus,  which  may  lead  to  perforation  with  the 
tube. 

3.  Aortic  aneurism. 

4.  Marked  arteriosclerosis. 

5.  Angina  pectoris. 

6.  Other  examinations  may  precede  the  passing  of  a  stomach 
tube.     Tabes    dorsalis,    tuberculosis,    nephritis,    and  -anemia    may 
produce  grave  gastric  symptoms.     A  detached  tenth  rib  may  point 
to  a  gastroptosis,  or  certain  stigmata  and  symptoms  may  indicate 
the  presence  of  hysteria. 

Preparation. — At  the  regular  breakfast  time  for  the  patient  he 
should  be  given  an  Ewald  test  meal  consisting  of  two  slices  of  white 

71 


72  LABORATORY    METHODS. 

bread,  with  the  crust  removed,  without  butter,  and  a  glass  of  warm 
water  or  weak  tea.  The  bread,  which  should  be  somewhat  dry, 
must  be  well  chewed,  'and  not  dipped  into  the  liquid,  but  washed 
down  with  it.  The  contents  are  to  be  removed  forty-five  minutes 
after  the  meal. 

Passing  the  Tube. — It  is  advisable  to  inform  the  patient  that  the 
operation  will  be  unpleasant,  but  not  painful.  The  tube  should  be 
warm,  and  should  be  lubricated  with  a  very  thin  coat  of  glycerin. 
The  patient  should  be  seated  in  a  chair  with  arms,  so  that  he  can 
grasp  them  with  his  hands,  his  head  thrown  well  back,  and  his 
mouth  wide  open.  Stand  on  the  right  side  of  the  patient,  with 
your  left  arm  around  his  head,  so  that  the  left  hand  can  be  used 
to  guide  the  tube  as  it  is  passed.  Seize  the  tube  about  five  inches 
from  the  tip,  and  place  the  tip,  pointing  downward,  against  the 
posterior  pharyngeal  wall,  at  the  same  time  directing  the  patient 
to  swallow.  Then,  holding  the  tube  with  the  fingers  of  the  left 
hand  to  keep  it  from  being  coughed  out,  push  it  steadily  and  rather 
rapidly  down  the  esophagus.  At  the  cardia  it  will  meet  with  a 
little  resistance,  but  this  is  soon  overcome,  and  the  tube  will  enter 
the  stomach.  If  it  meets  a  firm  resistance,-  it  is  most  probably 
against  the  stomach  wall,  and  should  be  drawn  back  an  inch -or 
two.  Direct  the  patient  to  close  his  lips  and  breathe  rapidly, 
which  will  distract  his  attention  and  help  to  prevent  retching.  If 
the  patient  is  very  irritable  or  nervous,  spray  the  pharynx  with  a 
weak  cocain  solution  a  few  minutes  before  passing  the  tube.  Gen- 
erally, if  care  is  taken  and  the  operator  does  not  use  too  much 
haste,  no  trouble  will  be  found  in  passing  the  tube. 

To  Remove  the  Contents  of  the  Stomach. — Grasp  the  tube  with 
the  right  hand  (Fig.  20),  closing  the  tube  at  A  with  the  thumb  and 
forefinger  of  the  same  hand.  Compress  the  bulb  and  close  the  tube 
at  B  with  the  fingers  of  the  left  hand,  and  immediately  release  at 
A.  The  bulb  will  expand,  and  the  contents  will  be  drawn  through 
the  tube  into  the  bulb.  Repeat  this  process  until  no  more  fluid  is 
obtained. 

If,  after  removing  the  contents  for  analysis,  it  is  desirable  to 
wash  out  the  stomach  for  therapeutic  purposes,  the  free  end  of  the 
tube  can  be  placed  in  a  vessel  of  warm  water,  and  the  valve  action 
of  the  fingers  reversed  so  as  to  pump  water  into  the  stomach.  In 
the  same  way  the  tube  can  be  used  as  an  air  compressor  to  dilate 
the  stomach,  so  that  it  can  be  outlined  by  percussion. 


CHEMISTRY   AND    BIOLOGY   OF   GASTRIC    JUICE. 


73 


The  tube  is  removed  by  a  slow,  steady  pull.  Give  the  patient  a 
drink  at  once  and  food  in  about  half  an  hour. 

Examination  of  the  Contents. — The  material  obtained  should  be 
examined  as  soon  as  possible  after  removal  in  order  to  avoid  the 
artifacts  of  continued  fermentation.  Note  the  odor  at  once  to 
determine  if  there  has  been  any  putrefaction.  Filter  the  material 
through  a  single  sheet  of  filter  paper.  Use  a  large  funnel,  as  the 
filtrate  will  pass  through  slowly  at  best.  Reserve  some  of  the  un- 
filtered  liquid  for  microscopic  examination. 

Macroscopic  Examination. — QUANTITY.  This  is  a  variable  fac- 
tor, and  therefore  no  standard  of  normal  can  be  given.  It  will 
vary  with  the  motor  activity  of  the  stomach  and  with  the  amount 


Fig.  20. — Method  of  removing  contents  from  stomach. 

of  secretion.  A  large  amount  may  signify  retention  or  hyperse- 
cretion,  or  both,  and  a  small  amount  may  indicate  hypermotility  or 
scanty  secretion.  The  chemical  and  microscopical  examinations 
must  be  made  as  a  check  for  the  quantity  of  material. 

COLOR.  The  normal  color  after  an  Ewald  meal  is  yellowish- 
white.  The  presence  of  red  blood  indicates  hemorrhage  at  the  time 
of  passing  the  tube,  and  may  or  may  not  have  been  caused  by  the 
tube,  but  is  generally  considered  as  a  sign  of  congestion.  Dark< 
brown  and  black  specks  or  particles  indicate  hemorrhages  previous, 
to  the  passing  of  the  tube,  and  are  partially  digested  blood  clots 
A  greenish-yellow  tinge  is  caused  by  bile,  which  is  often  forced 


74 


LABORATORY    METHODS. 


back  into  the  stomach  by  the  straining  and  retching  when  the  tube 
is  passed. 

PHYSICAL  CHARACTERISTICS.  The  material  in  health  consists 
chiefly  of  finely  divided  particles  of  the  food  taken.  .Mucus,  <>!' 
which  there  should  be  only  a  small  amount,  is  recognized  by  its 
tenacious  character.  Food  taken  at  a  previous  meal,  or  even  a  day 
or  two  before,  can  often  be  identified  by  bits  of  vegetable  or  meat 
fibers,  seeds,  and  skins  of  fruits  or  vegetables.  Of  these  the  most 
easily  recognized  are  the  red  skin  and  seeds  of  tomatoes  and  the 
skins  of  raisins. 

Pieces  of  mucosa  or  tumor  are  difficult  to  recognize,  and  suspi- 
cious materials  should  be  sectioned  and  examined  histologically. 
(See  Essence  of  Tissue  Diagnosis,  page  78.) 


D 


F 


G 


Fig.  21. — Microscopic  elements  of  major  and  minor  import  in  stomach  analyses.  Normal 
findings — A,  muscle  fibers  from  food;  B,  vegetable  cells  from  food;  C,  starch  grains 
of  food;  D,  fatty  needles  from  food;  E,  squamous  epithelium  from  mucosa.  Patholog- 
ical elements — F,  white  blood  cells,  normal  in  small  numbers;  G,  fed  blood  cells, 
rarely  normal  even  in  very  small  numbers;  H,  yeast  cells;  I,  sarcines;  J,  Oppler 
Boas  bacilli,  longer  rods. 

Microscopic  Examination. — Take  some  of  the  material  which 
remains  in  .the  filter,  and  press  a  small  amount  of  it  between  two 
large  glass  slides  or  between  two  plates  of  clear  glass.  Examine  it 
first  with  low  power  for  connective  tissue  fibers  and  pieces  of  mu- 
cosa and  tumors.  Examine  with  high  power  for  the  following 
(Fig.  21): 

BLOOD  CELLS.     These  may  be  in  their  normal  shape  or  crenatcd. 


CHEMISTRY   AND   BIOLOGY   OF   GASTRIC    JUICE.  75 

YEASTS.  These  are  elongated  bodies,  three  or  ten  microns  in 
length,  with  similar  smaller  processes  budding  out  from  them. 

SARCINES.  Sarcines  are  rather  large  cocci,  which  form  "cotton 
bale"  clusters  as  they  divide. 

OPPLER-BOAS  BACILLI.  These  are  long,  heavy  bacilli,  which  often 
occur  in  pairs,  and  may  be  found  in  long  chains  or  forming  angles 
with  each  other. 

Chemical  Analjcis. — QUALITATIVE.  Free  hydrochloric  acid. 
Mix  3  or  4  drops  of  Gunzburg's  reagent  and  an  equal  amount  of 
the  filtrate  on  a  porcelain  shell  or  on  the  bottom  of  a  clean  evapo- 
rating- dish,  and  heat  slowly  over  a  flame,  holding  the  dish  with 
the  fingers  in  order  not  to  burn  the  materials.  A  deposit  of  minute 
red  crystals  at  the  edge  cf  the  mixture  gives  a  distinct  rose-red 
color  when  free  hydrochloric  acid  is  present.  This  is  a  certain 
reaction. 

Lactic  acid.     In  a  large  test  tube  mix  5  cc.  of  the  filtrate  with' 
50  cc.  of  distilled  water,  and  add  2  drops  of  ferric  chlorid  (5-per- 
cent aqueous  solution).     If  lactic  acid  is  present,  a  greenish-yel- 
low color  appears. 

These  two  qualitative  tests  are  the  only  ones  of  any  value  to  the 
practitioner. 

QUANTITATIVE.  The  most  important  quantitative  analyses  are 
for  free  hydrochloric  acid  and  total  acidity,  and  these  may  be  made 
together.  To  10  cc.  of  the  filtrate  in  a  beaker  or  whisky  glass  add 
1  drop  of  dimethylamidoazobenzol  indicator.  Starting  with  the 
buret  filled  with  the  N/10  NaOH  to  the  0  cc.  mark,  add  the  NaOH 
to  the  filtrate,  a  drop  at  a  time,  stirring  constantly.  When  the 
pink  color  has  disappeared,  all  the  free  HC1  has  been  neutralized, 
and  the  reading  of  the  buret  gives  the  number  of  cubic  centimeters 
of  NaOH  used  in  the  neutralizing.  As  only  10  cc.  of  filtrate  were 
used,  this  number  multiplied  by  10  will  give  the  percentage  of 
IIC1  in  100  cc.  of  the  filtrate  in  terms  of  N/10  NaOH.  For  ex- 
ample, if  4.5  cc.  N/10  NaOH  are  required  to  neutralize  the  free 
HC1  in  10  cc.  of  the  stomach  washings,  then  10X4.5,  or  45,  is  the 
percentage  of  free  HC1  in  terms  of  N/10  NaOH. 

To  the  same  filtrate  now  add  2  drops  of  phenolphthalein,  and 
again  titrate  with  NaOH  until  the  first  permanent  pink  occurs. 
The  reading  of  the  buret  X  10  now  indicates  the  total  acidity,  and 
this,  minus  the  free  acid,  is  practically  the  amount  of  combined 
acid. 


76  LABORATORY    METHODS. 

In  case  that  enough  filtrate  can  not  be  obtained  to  furnish  10  cc. 
for  the  quantitative  tests,  use  as  much  as  possible  and  adjust  the 
figures  according  to  the  following  example: 

Number  of  cubic  centimeters  used  :  10  :  :  NaOH  used  :  x,  x  equal- 
ing the  number  of  cubic  centimeters  of  NaOH  that  would  be  re- 
quired by  10  cc.  of  the  filtrate. 

If  6  cc.  of  the  filtrate  required  3  cc.  NaOH  for  free  HC1,  then 

6  :  10  : :  3  :  x 

x  =  5 
5  X  10  =  50=  percentage  of  free  HC1. 

If  2  cc.  more  of  NaOH  are  required  for  the  total  acidity,  then 

6  :  10  ::  5  :  x 
x  =  8.33 

8.33  X  10  =  83.3=  percentage  of  total  acidity. 
83.3  —  50  =  33. 3=  percentage  of  combined  acid. 

Interpretation  of  Findings. — Yeasts  require  time  to  grow,  and 
may  be  considered  as  indicative  of  some  retention  and  fermenta- 
tion. 

Sarcines  can  grow  in  free  acid,  and  are  generally  indicative  of 
hyperacidity. 

Oppler-Boas  bacilli  are  generally  found  in  hypoacidity,  as  they 
do  not  grow  well  in  free  acid.  They  produce  lactic  acid,  and 
where  one  is  found  the  other  may  generally  be  expected. 

In  ulcer  of  the  stomach  the  free  and  combined  hydrochloric  acids 
are  increased,  hemorrhage  is  common,  and  sarcines  may  be  pres- 
ent. There  is  often  a  hypersecretion,  so  that  large  amounts  of 
material  may  be  obtained  in  washing.  Retention  will  be  shown. 
No  lactic  acid  is  found  in  the  majority  of  cases. 

Carcinoma  of  the  stomach  is  accompanied  by  a  diminished  hy- 
drochloric acid  content,  and  often  no  acid  is  found.  The  Oppler- 
Boas  bacillus  is  nearly  always  found,  and  is  considered  by  some  as 
pathognomonic  of  carcinoma.  The  secretion  is  scanty,  and  only 
small  amounts  of  material  are  obtained  after  a  test  meal.  Lactic 
acid  is  generally  found. 

Chronic  gastritis  gives  a  variety  of  findings,  and  the  most  con- 
stant of  these  is  mucus  in  large  amounts  after  a  meal  or  after  a 
fast  of  a  few  hours. 


CHEMISTRY   AND    BIOLOGY   OP   GASTRIC    JUICE.  77 

Gastric  neuroses  may  be  indicated  by  the  presence  of  abnormally 
large  or  deficient  quantities  of  stomach  acids  without  the  presence 
of  pathological  elements. 

Sources  of  Error. — The  main  sources  of  error  may  be  traced  to 
inaccurate  quantitative  test  solutions.  When  making  the  iron  test 
for  lactic  acid  it  is  advisable  to  run  a  control  test,  as  the  final  green 
color  is  often  difficult  to  determine.  It  may  be  very  tedious  to 
filter  the  sample,  which  is  especially  the  case  when  much  mucus 
is  present,  and  it  is  suggested  to  pass  it  through  a  single  piece  of 
cheese  cloth  before  using  the  paper. 

Value  and  Limitations. — A  thorough  physical  examination 
should  precede  every  stomach  analysis.  If  this  fails  to  reveal  the 
nature  of  the  disorder,  and  there  are  no  contraindications,  the  physi- 
cian should  proceed  with  the  analysis  of  the  gastric  juice  and  ex- 
pect to  learn  much  from  the  examination. 

It  must  be  borne  in  mind  that  the  results  of  a  laboratory  exam- 
ination should  not  overshadow  those  obtained  by  other  measures, 
and  that  each  link  in  the  chain  of  evidence  must  be  equally  strong 
in  order  that  a  safe  diagnosis  may  be  established. 

Less  Frequently  Applied  Procedures. — The  stomach  whistle,  the 
gastric  bucket,  and  mirror  have  yet  to  earn  a  place  in  the  equip- 
ment of  the  general  practitioner. 

Many  chemical  and  microscopic  examinations  of  scientific  inter- 
est have  been  omitted  in  order  that  the  more  useful  procedures  in 
diagnostics  might  be  emphasized. 

NOTE — Weinstein  (Archiv.  of  Bias*.,  July,  1912)  calls  attention  to  the  fact  that  many 
valuable  points  may  be  gained  by  the  gross  appearance  of  the  stomach  contents.  Thus, 
he  states,  chronic  gastritis  is  characterized  by  thick  contents  with  considerable  amounts 
of  stringy,  glassy  mucus.  In  the  hyperacid  states,  the  prrticles  of  bread  are  heavy;  and 
fall  to  the  bottom  of  the  vessel  like  grains  of  sand.  In  hypoacidity,  the  particles  of 
bread  are  more  likely  to  be  flaky  and  float. 


CHAPTER  VI. 

ESSENCE  OF  TISSUE  DIAGNOSIS. 

The  subject  matter  of  this  chapter  has,  for  convenience,  been 
treated  under  two  divisions — "Essence  of  Frozen  Sections"  and 
"Essence  of  Celloidin  Sections."  The  first  division  treats  of  the 
rapid  tissue  diagnosis  in  the  operating  room  by  means  of  frozen 
sections,  but,  as  it  is  often  desirable  to  proceed  more  slowly,  the 
treatment  in  the  second  division  offers  a  simple  technic.  Both 
methods  have  been  used  by  the  authors  with  the  most  gratifying 
results.  Curettings  from  the  cervix  uteri,  specimens  from  sus- 
pected breast  tumors,  and  other  tissues  are  examined  by  the  first 
method  and  a  diagnosis  made  within  five  minutes,  provided  that 
the  technic  has  been  thoroughly  mastered  by  practice  with  pieces 
of  steak,  lumps  of  sausage,  etc. 

In  this  chapter  no  attempt  is  made  to  teach  pathology,  but  the 
practitioner  may,  however,  gain  much  information  on  this  subject 
by  frequent  reference  to  the  high-class  atlas. 


ESSENCE  OF  FROZEN  SECTIONS. 

Apparatus. — The  articles  forming  the  equipment  have  been  listed 
in  the  order  of  their  use. 


1.  Whisky  glass. 

2.  Formalin,   10-percent. 

3.  Scalpel. 

4.  Forceps. 

5.  Microtome. 

6.  Common  bottle  corks. 

7.  Gum  arabic   (concentrated  aqueous 

solution)   and  pipette. 

8.  Tube  of  ethyl  chlorid. 

9.  Section  knife,  or  razor. 


10.  Watch  glass,  or  saucer. 

11.  Distilled  water. 

12.  Needle  and  section  Jifter,  or  sub- 

stitutes. 

13.  Slides. 

14.  Thionin  stain  and  pipette. 

15.  Cover  glass. 

16.  Filter  paper. 

17.  Microscope  and  accessories. 


References. — Mallory  and  Wright:  Pathological  Technique;  Diirck :  Atlas  of  Patho- 
logic Histology;  Warthin :  Laboratory  Work  in  Pathology;  Hall  and  Herxheimer: 
Pathological  Methods. 

78 


ESSENCE   OF   TISSUE   DIAGNOSIS. 


79 


With  the  exception  of  the  microscope  and  small  microtome,  the 
entire  outfit  may  be  kept  in  a  small  box  about  12x5x3  inches,  which 
may  be  easily  taken  to  the  hospital  or  home  of  the  patient.  While 
quite  as  reliable  results  may  be  obtained  with  this  outfit  as  with  the 
more  expensive  apparatus,  it  must  not  be  inferred  that  the  speci- 
mens will  be  beautiful.  The  frozen  section  is,  at  best,  thicker  than 
the  celloidin  cutting,  but,  so  far  as  diagnosis  is  concerned,  shows 
quite  as  much. 

Microtome. — A  perfected  microtome  is  a  valuable,  but  expensive, 
instrument.  The  authors  have  tried  many  substitutes,  and  have 
found  that  a  thin  section,  made  with  a  razor,  using  a  pair  of  tissue 
forceps  and  an  ethyl  chlorid  spray,  is  satisfactory.  Relihan  sug- 
gests the  use  of  a  small  rubber  band  wrapped  around  the  points  of 


B  C 

Fig.   22. — Substitutes  for  the   perfected  microtome.      A,   Relihan's   suggestion,    costs    10 
cents ;  B,  hand  microtome,  costs  $6  ;  C,  table  microtome,  costs  $12  to  $14. 

the  forceps  (Fig.  22),  the  upper  edges  of  the  blades  serving  as  ways 
and  the  razor  being  thus  supported  at  a  cutting  angle.  He  says: 
"The  first  section  will  be  too  thick,  but,  after  freezing  the  third 
or  fourth  time  and  repeating  the  same  procedure,  I  have  had  no 


80  LABORATORY   METHODS. 

trouble  in  getting  thin  sections.  The  contraction  of  the  forceps 
blades  seems  to  be  so  much  quicker  than  the  tissue  contraction  that 
the  projecting  portion  is  about  the  right  thickness  for  a  section. 
By  going  through  this  procedure  .  .  .  these  sections  answered 
my  purpose  perfectly."1  The  hand  microtome  (Fig.  22)  answers 
for  thick  sections. 

The  authors  recommend  the  use,  whenever  possible,  of  a  table 
microtome,  which  is  supplied  by  all  optical  firms,  and  with  it  prac- 
tically every  section  is  thin  enough  for  study.  Although  the 
description  is  confined  to  this  instrument,  all  directions  may  be  so 
modified  as  to  be  applicable  to  any  substitute. 

Freezer. — Certain  ether  and  rhigolene  freezers,  ranging  in  price 
from  $6  to  $10,  are  on  the  market  and  give  good  results.  They 
do  not,  however,  freeze  under  certain  atmospheric  conditions,  nor 
are  they  easily  manipulated  when  haste  is  desired.  The  ethyl 
chlorid  spray,  used  in  minor  surgery,  is  more  convenient,  can  be 
had  at  a  modest  price,  -and  the  results  of  its  use  are  so  encouraging 
that  it  is  recommended  to  the  general  practitioner. 

Knife. — Any  razor  will  answer,  especially  if  one  side  of  the 
blade  is  flat — not  hollow  ground.  The  authors  have  successfully 
used  the  new  Bausch  &  Lomb  chisel  knife,  an  inexpensive  instru- 
ment, for  frozen  sections. 

Fixing  and  Mounting. — "With  the  scalpel  and  tissue  forceps  the 
specimen  is  cut  into  a  small  block  about  the  size  of  a  pea  and 
dropped  immediately  into  a  tumbler  containing  10-percent  forma- 
lin (4-percent  formaldehyd),  when  it  is  carried  to  where  the  ex- 
amination is  to  be  made,  and  the  short  time  that  it  is  in  the  solu- 
tion will  aid  in  freezing  it.  Alcohol  delays  freezing  and  does  not 
answer  the  purpose.  The  tissue  is  then  seized  with  the  forceps 
and  dipped  into  a  concentrated  aqueous  solution  of  acacia,  after 
which  it  is  placed  on  the  top  of  an  ordinary  cork  previously 
mounted  on  the  microtome. 

Freezing  and  Sectioning. — The  tissue,  in  its  gummy  capsule,  is 
frozen  at  once  by  using  the  ethyl  chlorid  spray.  Very  little  of 
this  liquid  is  necessary  if  the  operator  blows  vigorously  on  the 
tissue,  and  under  such  treatment  it  should  harden  almost  in- 
stantly. Sections  are  quickly  obtained,  and  should  be  as  thin  as 
possible. 

Staining. — The  sections  are  dropped  immediately  into  some  dis- 

1  Journal  of  American  Medical  Association,  November  6,  1909. 


ESSENCE   OF   TISSUE   DIAGNOSIS.  81 

tilled  water,  which  should  not  be  too  cold  if  gocd  stains  are  de- 
sired. Place  a  section  on  a  clean  slide  and  add  immediately  several 
drops  of  carbol-thionin.  Permit  staining  to  proceed  for  at  least 
one  minute,  and  take  up  excess  of  fluid  with  a  little  filter  paper. 
Add  a  clean  cover  glass  and  examine  under  low  power. 

Preparing  the  Stain. — The  stain  is  so  easily  made  up  that  the 
powdered  thionin  is  recommended.  The  making  of  the  liquid 
stain,  as  described  by  Strouse,  is  as  follows : 

1.  Take  2  grams  of  pure  thionin. 

2.  Make  up  a  saturated  aqueous  solution. 

3.  Allow  the  solution  to  stand  at  least  six  hours,  stirring  occa- 
sionally. 

4.  Filter. 

5.  Mix  the  clear  solution  with  equal  parts  of  2-percent  phenol. 
The  stain  improves  with  age,  but  an  occasional  filtering  may  be 

necessary. 

Technic. — A  brief  outline  of  the  technic  of  quick  tissue  diagnosis 
is  as  follows : 

1.  Cut  into  small  block. 

2.  Transfer  in  10-percent  formalin. 

3.  Mount  on  cork  in  acacia  solution. 

4.  Freeze  with  ethyl  chlorid. 

5.  Section. 

6.  Float  in  warm  distilled  water. 

7.  Drop  on  slide. 

8.  Add  stain. 

9.  Add  cover  glass. 
10.  Examine. 

Examination  of  Section. — Too  much  must  not  be  expected  from 
this  method,  and  even  a  person  with  some  experience  in  the  ordi- 
nary technic  may  be  confused  at  first.  Compared  with  celloidin 
sections,  these  are  much  thicker  and  do  not  stain  so  well.  With  a 
little  patience,  however,  and  when  applied  to  certain  selected  cases, 
it  proves  a  very  valuable  addition  to  the  medical  laboratory. 
Examinations  should  be  made  principally  with  a  low-power  ob- 
jective, especially  in  diagnosticating  tumors.  The  thionin  stain  is 
usually  not  intense,  so  that  it  may  be  advantageous  to  narrow  the 
diaphragm.  Nuclei  are  stained  a  dark-blue  color,  while  the  proto- 
plasm takes  on  a  reddish  purple  tinge. 

Errors  in  Technic. — Alcohol  can  not  be  substituted  for  -formalin, 


82  LABORATORY    METHODS. 

as  it  prevents  or  delays  freezing.  The  refrigeration  must  be  com- 
plete, and  the  tissue  should,  figuratively  speaking,  become  as  hard 
as  a  rock  before  any  attempt  at  sectioning  is  undertaken.  At  the 
first  indication  of  thawing,  the  tissue  should  be  again  frozen  if  more 
sections  are  desired.  'A  dull  knife  and  a  straight  cut  cause  the 
tissue  to  crumble.  The  knife  should  be  drawn  at  an  angle  best 
estimated  by  experience.  Staining  should  cause  no  trouble,  and  a 
thionin  solution  which  refuses  to  stain  after  it  has  been  prepared 
two  weeks  should  be  rejected.  Neither  the  stain  nor  the  wash 
which  precedes  it  should  be  cold  if  good  results  are  desired. 

Other  Freezing  Methods. — In  hospitals  and  other  institutions, 
where  expense  must  serve  convenience,  the  carbon  dioxid  freezing 
tank  and  attachment  are  used. 

Value  and  Limitations. — The  freezing  methods  are  used  at  pres- 
ent only  in  these  diagnostic  indications  which  have  been  previously 
considered  (page  78),  and  are  not  advised  where  haste  is  not 
necessary,  as  the  sections  are  thick,  stain  poorly,  and  are  often  of 
no  service  in  the  differentiation  of  cellular  elements.  In  its 
sphere,  however,  the  value  of  the  rapid  method  can  hardly  be  over- 
estimated. The  technic  can  not  be  mastered  in  a  few  minutes. 
Repeated  attempts  with  controls — tissues  of  known  sources — 
should  be  made,  and  the  apparatus  collected  and  held  in  reserve 
for  the  time  of  need. 

ESSENCE  OF  CELLOIDIN  SECTIONS. 


Apparatus.— 

1.  Absolute  alcohol. 

2.  Blotter  system. 

3.  Carbol-xylol. 

4.  Celloidin  shavings. 

5.  Corks. 

6.  Distilled  water. 

7.  Eosin   (1-percent  solution). 

8.  Ether. 


9.  Glass  covers. 

10.  Mayer's  hemalum  solution. 

11.  Microscope  and  accessories. 

\-2.  Microtome   and   knife,    or    substi- 
tutes. 

13.  Section  lifter. 

14.  Staining  dishes,  or  substitutes, 
l.'i.  Whisky  glasses. 


Of  all  the  celloidin  methods,  this  seems  to  be  the  most  simple 
and  rapid,  as  well  as  sufficiently  accurate,  technic  for  those  desir- 
ing to  do  this  kind  of  work. 

Preparing  Celloidin  Solutions.—  Shering's  celloidin  shavings 
are  sold  in  1-ounce  bottles  by  optical  firms.  A  stock  solution  is 
prepared  by  dissolving  about  2  drams  of  the  shavings  in  a  6-ounce 


ESSENCE  OF   TISSUE  DIAGNOSIS.  83 

bottle  filled  with  equal  parts  of  absolute  alcohol  and  ether.  Keep 
well  stoppered,  shaking  occasionally,  and  a  perfect  solution  should 
occur  within  twenty-four  hours.  This  is  the  stock  solution,  or  the 
thick  celloidin  solution.  To  prepare  the  thin  celloidin  solution, 
dilute  some  of  the  stock  solution  with  an  equal  quantity  of  a  solu- 
tion of  equal  parts  of  absolute  alcohol  and  ether. 

All  of  these  solutions  are  very  volatile  and  highly  inflammable, 
and  must  be  kept  in  well-stoppered  bottles.  When  used  in  glasses 
or  staining  dishes,  .the  vessels  should  be  covered  with  small  squares 
of  window  glass,  similar  to  those  used  when  examining  urine  sedi- 
ments. In  case  the  solution  must  stand  over  night,  a  little  petro- 
latum should  be  placed  around  the  upper  edge  of  the  vessel  before 
applying  the  cover. 

Rapid  Hardening  and  Infiltration. — This  method,  somewhat 
modified,  is  used  in  the  pathological  laboratory  at  the  University  of 
Michigan.  Each  solution  may  be  kept  in  a  small  tumbler,  but 
evaporation  must  be  avoided.  A  piece  of  the  tissue  about  the  size 
of  a  pea  is  selected  and  passed  through  the  solutions  as  follows : 

1.  Three  changes  of  absolute  alcohol  during  an  hour. 

2.  Equal  parts  of  ether  and  absolute  alcohol,  one-half  hour. 

3.  Thin  celloidin  over  night. 

Imbedding. — Remove  the  tissue  from  the  thin  celloidin  and  place 
it  on  the  flat  surface  of  a  wide,  but  not  too  thick,  cork — a  cork 
similar  to  those  used  in  small  salt-mouthed  bottles.  Permit  the 
celloidin  to  partially  "set,"  thus  gluing  the  preparation  to  the 
cork,  and  then  pour  on  it  a  little  thin  celloidin  and  blow  on  it.  By 
repeating  this  process  several  times  the  celloidin  may  be  built  up 
around  the  tissue.  Now  float  the  cork,  tissue  face  downward,  in 
absolute  alcohol  for  five  hours  or  longer. 

Sectioning. — (See  page  80.)  Do  not  use  the  chisel  knife,  but 
an  ordinary  microtome  knife  or  a  razor.  In  case  the  latter  is  em- 
ployed, at  least  the  under  surface  should  be  flat,  and  the  upper 
surface  must  be  kept  covered  with  alcohol  during  the  cutting.  The 
section  should  be  made  by  one  continuous  cut,  using  a  good  "cut- 
ting angle."  Sections  are  placed  in  ordinary  alcohol  before  stain- 
ing. 

Systematic  Staining  (Authors'  Method). — By  using  picrocar- 
min,  less  time  will  be  taken,  but  the  results  are  not  nearly  so 
good  as  where  hemalum  and  eosin  are  used.  Instead  of  staining 
dishes,  watch  glasses  or  saucers  may  be  used.  Small  tin  ointment 


84  LABORATORY   METHODS. 

boxes  possess  many  advantages,  and,  if  they  are  new,  the  sections 
are  easily  seen  against  the  bright  tin  background.  Before  begin- 
ning any  portion  of  the  staining,  each  dish  should  be  supplied  with 
its  solution,  covered  with  a  glass  plate,  and  be  arranged  in  the 
order  of  their  use.  A  watch  or  clock  should  be  constantly  in  full 
view.  The  plan  of  systematizing  here  given  has  many  advantages 
over  the  more  haphazard  methods. 

Each  dish  should  rest  on  a  small  piece  of  blotter,  which  not  only 
serves  to  keep  the  laboratory  table  clean,  but  on  it  may  be  placed 
the  number  of  the  dish,  the  name  of  the  solution,  and  the  staining 
time.  This  arrangement  will  not  only  keep  the  worker  from  be- 
coming confused,  but,  if  laid  aside  between  analyses,  it  will  not 
always  be  necessary  to  read  up  the  method  when  each  tissue  is 
examined,  which  is  of  importance  to  the  busy  practitioner.  The 
following  procedure  not  only  illustrates  what  is  meant  by  the 
"systematic"  method,  but  serves  to  describe  the  routine  of  celloidin 
staining  as  recommended  to  the  general  practitioner. 

1.  Hemalum,  one  to  ten  minutes — nuclear  stain. 

2.  Distilled  water,  one  minute — wash. 

3.  Eosin,  one  to  five  minutes — cytoplasm  stain. 

4.  Distilled  water,  one  minute — wash. 

5.  Ninety-five-percent  alcohol,  one  minute — dehydrating. 

6.  Absolute  alcohol,  one  minute — dehydrating. 

7.  Carbol-xylol,  one  minute — clearing. 

8.  Mount  in  balsam. 

The  duration  of  staining  depends  on  the  strength  of  stain  and 
kind  of  tissues.  With  a  little  practice  this  method  should  give  no 
trouble.  The  nuclei  should  appear  as  dark-purple  spots  on  a  pink 
cytoplasm.  In  case  it  is  not  desired  to  keep  the  specimens,  the 
technic  may  be  stopped  short  of  the  alcohols  and  the  examination 
be  made  in  water. 

Curettings. — These  may  be  prepared  for  examination  by  either 
the  freezing  or  celloidin  method,  several  pieces,  instead  of  one,  be- 
ing mounted  in  acacia  or  imbedded  in  celloidin  respectively. 

Paraffin  Imbedding. — A  description  of  this  method  is  left  to  the 
larger  text  books.  It  is  true  that  very  beautiful  specimens  may  be 
obtained  by  the  use  of  this  substance,  but  for  a  small  number  of 
specimens  it  can  hardly  be  recommended.  Its  application  neces- 
sitates the  purchase  of  expensive  equipment,  and  it  is  a  slow  method 
so  far  as  diagnosis  is  concerned. 


CHAPTER  VII. 


DETECTION  OF  THE  COMMON  POISONS. 


Apparatus. — 

1.  Ring  stand. 

2.  Evaporating  dish,  or  porous  porce- 

lain plate. 

3.  Marsh  apparatus. 

4.  Test  tubes,  stand,  and  holder. 

5.  Funnel  and  filter  paper. 

6.  Reagents,   which    should   be   chem- 

ically pure  and  obtained  in  small 
amounts  from  reliable  companies 
— carbolic  acid,  chromic  acid, 
hydrochloric  acid  (arsenic  free), 


nitric  acid,  sulphuric  acid,  am- 
monium hydroxid,  calcium  chlo- 
rid,  powdered  charcoal  (wood), 
ferric  chlorid,  Nessler's  reagent, 
phenolphthalein  (1-percent  alco- 
holic solution),  potassium  bi- 
chromate (dichromate),  sodium 
hypochlorite  (should  be  made  up 
fresh  by  pharmacist ) ,  stannous 
chlorid,  sweet  oil,  zinc  (arsenic 
free ) . 


In  this  book  are  described  only  the  good  tests,  which  are  usually 
the  simple  ones,  and,  with  a  view  of  limiting  expense,  the  selections 
of  tests  have  been  made  in  such  manner  that  one  reagent  may  be 
available  for  the  detection  of  several  different  drugs.  For  exam- 
ple, the  ferric  chlorid  can  be  used  in  the  identification  of  morphin, 
opium,  and  carbolic  acid,  and  the  same  reagent  may  be  used  in 
urinalysis.  As  far  as  possible  the  authors  have  avoided  indicating 
the  rare  and  more  costly  reagents. 

These  are  sample  tests,  and  are  made  for  the  purpose  of  satisfy- 
ing the  physician  or  his  patient.  Only  an  isolation  of  the  poison 
in  its  pure  form  is  accepted  as  expert  testimony,  and  it  is  not  the 
object  of  this  book  to  enter  that  field. 

There  are  certain  limitations  to  the  value  of  many  of  these  tests, 
but  these  are  not  always  pointed  out  because  substances  giving 
similar  reactions  are  not  usually  met  under  the  same  conditions. 
For  example,  the  physician  observes  certain  symptoms  in  a  patient 
which  he  believes  to  be  due  to  phenol  poisoning,  and  at  once  begins 
examining  samples  of  the  drug,  food,  or  beverage  under  suspicion. 
The  fact  that  anilin  might  give  a  similar  reaction  seems  hardly  to 


References. — Peterson  and  Haines:  Legal  Medicine  and  Toxicology;  Edmunds  and 
Cushny:  Experimental  Pharmacology;  Autenrieth:  Detection  of  Poisons;  Riley:  Toxi- 
cology; Tanner:  Poisons. 

85 


86 


LABORATORY    METHODS. 


DETECTION   OF   THE    COMMON   POISONS.  87 

enter  into  the  question.  So  far  as  the  common  poisons  are  con- 
cerned, each  reaction  is  specific,  and  should  at  once  put  the  physi- 
cian on  the  right  track,  but  such  conclusion  would  not  he  accepted 
in  a  court  as  expert  evidence.  While  these  reagents  are  few  and 
not  expensive,  they  are  not  always  to  be  obtained  by  the  physician 
at  a  moment's  notice,  and,  if  he  has  a  considerable  amount  of  this 
work  to  do,  he  should  keep  on  hand  a  sufficient  quantity  to  meet  his 
needs. 

All  poisons  are  not  freely  soluble,  so  that  the  sample  should  not 
be  filtered.  Much  better  results  may  be  obtained  by  straining  out 
the  larger  pieces  of  foreign  material,  and  decantation  may  often 
serve  this  purpose.  Only  the  most  common  poisons  are  included, 
and  it  has  been  deemed  advisable  to  omit  aconite  and  other  poisons 
of  perhaps  secondary  import  for  the  reason  that  they  are  not 
usually  employed  to  destroy  human  life.  For  the  sake  of  sim- 
plicity, names  of  the  tests  are  not  given,  as  many  have  been  modi- 
fied to  such  an  extent  that  it  would  be  difficult  to  give  a  definite 
nomenclature. 

In  the  poison  tests  distilled  water  should,  if  possible,  be  used, 
although  it  is  not  absolutely  necessary.  In  case  ordinary  water  is 
used,  it  should  contain  neither  lead  nor  any  other  common  poisons 
— in  other  words,  it  should  be  gocd  drinking  water. 

Unfortunately  there  are  no  simple  tests  for  wood  alcohol  and 
antipyrin  which  can  be  properly  recommended,  while  several  other 
tests — for  example,  the  ergot  test — are  none  too  satisfactory. 

Sources  of  Every-Day  Poisons. — "Dopes"  are  neither  always 
served  ' '  straight, ' '  nor  are  they  invariably  so  preferred  by  suicides. 
Some  of  the  mere  common  mixtures  or  adulterations  are : 

Abortifacients — ergot,  yellow  phosphorus. 

Bad  whisky  ("rot  gut") — laudanum,  wood  alcohol. 

Bitters    (bracers) — strychnin,  alcohol  in  large  proportion. 

Bug  poisons — arsenic,  mercury  salts. 

Coke,  coc,  certain  colas,  fatigue  powders — cocain. 

Cough  syrups,  soothing  syrups,   pa  pine — morphin. 

Drug  cures — morphin,  cocain,  alcohol,  hyoscin,  etc. 

Eye  drops,  clap  medicines — zinc  salts,  silver  salts. 

Headache  powders — acetanilid,  antipyrin. 

Knock-out  drops — chloral,  laudanum. 

Liniments — certain  ones  have  been  found  to  contain  wood  alco- 
hol. 


88  LABORATORY   METHODS. 

Lye — fixed  alkalies. 

.Matches — yellow  phosphorus  (some  of  the  safety  matches  con- 
tain the  nonpoisonous  red  phosphorus). 

Paris  green — a  mixture  of  copper  acetate  and  copper  arsenite. 

Rat  poisons — arsenic ;  some  contain  phosphorus,  others  contain 
cultures  of  the  Danycz  virus  or  certain  strains  of  paratyphoid 
bacilli. 

Sex  stimulants — cantharidin. 

Skin  "beautifiers" — arsenic. 

Inasmuch  as  many  poisons  have  been  omitted,  there  has  been 
no  attempt  at  classification  other  than  an  alphabetical  arrange- 
ment. For  convenience,  the  names  of  necessary  reagents  precede 
the  test.  The  letter  "x"  refers  to  the  unknown  substance. 

It  is  not  necessary  that  percentage  solutions  should  cause  con- 
fusion. In  qualitative  tests,  only  approximate  values  are  intended 
unless  otherwise  stated.  A  practical  method  of  estimating  these 
solutions  is  given  in  General  Information,  page  192. 

Acetanilid. — Concentrated  hydrochloric  acid,  concentrated  aque- 
ous solution  of  carbolic  acid,  ammonium  hydroxid  solution,  very 
dilute  chromic  acid  solution.  Boil  "x"  with  about  1/2  dram  of 
concentrated  hydrochloric  acid  and  cool.  Add  1  dram  of  the  car- 
bolic solution,  and  then  add  a  few  drops  of  the  chromic  solution. 
After  two  minutes  a  dirty  purple  or  red  should  appear.  Add  a 
few  drops  of  the  ammonium  hydroxid  solution  and  shake.  Within 
two  minutes  a  greenish  or  indigo  color  should  appear. 

Alkalies  Versus  Mineral  Acids. — Phenolphthalein  (1-percent  al- 
coholic solution). 

1.  Alkalies  have  a  soapy  "feel." 

2.  Nitric  and  hydrochloric  acids  have  characteristic  odors. 

3.  Acids  act  on  carbonates  with  gas  formation. 

4.  Acids  show  a  tendency  to  exhibit  a  sour  taste  even  in  very 
dilute  solution. 

5.  Test  with  phenolphthalein.     Alkalies  in  very  small  amounts 
impart  to  this  indicator  a  beautiful  red  color,  whereas  acids  produce 
no  effects. 

Alcohol. — Sulphuric  acid  (50-percent),  potassium  bichromate. 
Add  to  i/£  dram  of  "x"  14  dram  of  the  acid,  and  drop  into  the 
mixture  a  crystal  of  the  bichromate.  A  green  color  should  appear. 

Ammonia. — Hydrochloric  acid.  Dip  a  stirring  rod  into  the  acid 
and  hold  near  "x."  Wliite  fumes  should  appear.  The  charac- 


DETECTION    OF    THE    COMMON    POISONS. 


89 


teristic  odor  of  ammonia  as  well  as  the  gas  is  lost  on  standing. 
Samples  for  examination  should  be  tightly  corked. 

Arsenic. — Hydrochloric  acid,  zinc,  sodium  hypo  chlorite,  calcium 
chlorid.  Mix  "x, "  4  drams  of  hydrochloric  acid,  several  pieces  of 
zinc,  and  1  ounce  of  water  (distilled  or  drinking)  in  a  small  Marsh 
apparatus,  and  cork.  Do  not  inhale  fumes.  Do  not  light  gas 
until  you  are  sure  all  air  has  been  expelled  from  the  bottle.  Test 
by  collecting  samples  in  inverted  bottle,  and,  when  these  will  burn 
without  explosive  violence,  all  air  has  been  removed. 

Fig.  24  shows  how  a  Marsh  apparatus  may  be  constructed  with 
a  bottle,  a  cork,  and  a  graduated  5-cc.  pipette, 
and  illustrates  how  the  hydrogen  must  be  collected 
for  testing.  There  must  be  no  leaks  in  the  ap- 
paratus. Now  carefully  light  the  gas,  as,  in  case 
any  air  is  present,  a  violent  explosion  will  occur. 
Be  careful  to  inhale  none  of  the  fumes,  which 
give  off  a  garlic-like  odor  and  are  very  poisonous. 
Hold  one  of  the  unglazed  porcelain  plates  in  the 
flame,  and,  if  a  sublimate  is  deposited  which  is 


P. 


C 


Fig.  24. — Improvised  Marsh  apparatus.  A,  bottle  used  as 
generator;  B,  pipette,  such  as  is  used  in  stomach  tests, 
the  expanded  portion  of  which  contains  calcium  chlorid 
crystals:  C,  bottle  which  serves  as  a  receiver  for  col- 
lecting and  testing  the  hydrogen. 

soluble  in  sodium  hypochlorite,  arsenic  is  present. 
Some  difficulty  may  be  experienced  in  intro- 
ducing calcium  chlorid  into  the  enlarged  por- 
tion of  the  tube.  Small  crystals  shoufd  be  used, 
and  it  is  not  necessary,  for  practical  purposes, 
that  all  these  lie  neatly  in  the  enlarged  portion  of 
the  tube,  nor  is  it  imperative  that  this  enlargement  should  be  en- 
tirely filled.  If  a  thistle  tube  can  be  obtained  and  passed  through 
the  cork,  its  lower  end  diving  well  below  the  liquid,  fresh  acid  may 
be  added  from  time  to  time  as  necessary.  The  amounts  of  reagents 
need  not  be  accurate,  and  necessarily  vary  with  the  size  of  the  bot- 
tle. "When  cleaning  apparatus,  avoid  inhaling  odors.  Throw 
away  the  zinc. 


90  LABORATORY    METHODS. 

The  following  instructions  should  be  observed. 

1.  Have  all  connections  tight. 

2.  Do  not  inhale  fumes. 

3.  Do  not  explode  your  apparatus. 

4.  When  lighting  the  gas,  use  a  long  rod  to  support  match  in 
order  to  guard  against  injury  if  an  explosion  should  occur. 

Atropin,  Hyoscin,  Etc. — Both  dilate  the  pupil  of  a  dog's  eye. 
When  a  sample  of  atropin  is  heated,  a  honey-like  odor  is  given  off, 
which  may  be  intensified  by  the  addition  of  oxidizing  agents. 

Bacteria. — It  seems  that  the  future  toxicologist  must  be. trained 
to  recognize  certain  pathogenic  bacteria,  especially  the  typhoid  ba- 
cillus. Their  isolation  and  identification  are  tedious,  discourag- 
ing, and  often,  impossible,  even  for  the  expert.  The'  physician 
should  bear  in  mind  this  new  method  of  voluntary  contamination 
of  food  and  prescriptions. 

Cantharidin. — Sweet  oil.  Dissolve  some  of  the  suspected  ma- 
terial in  hot  sweet  oil,  and  shake  well.  When  the  oil  rises  to  the 
top  of  the  mixture,  decant  it  into  a  separate  vessel.  Apply  sev- 
eral drops  to  some  adhesive  plaster  and  place  it  on  the  chest,  allow- 
ing it  to  remain  in  position  about  ten  hours.  A  positive  test  is 
shown  by  the  presence  of  a  blister,  or  at  least  a  severe  reddening, 
where  each  drop  touches  the  integument.  Alkalies,  mineral  acids, 
and  other  poisons  which  might  give  a  similar  test  are  identified  in 
a  different  manner. 

Carbolic  Acid. — Dilute  ferric  chlorid  solution,  dilute  hydro- 
chloric acid.  Add  to  "x"  a  few  drops  of  the  ferric  chlorid  solu- 
tion, when  a  green,  blue,  or  violet  color  should  appear,  depending 
on  the  amount  of  the  poison  present.  Then  add  a  few  drops 
of  the  hydrochloric  acid,  when  a  lemon-yellow  color  will  take  the 
place  of  the  blue.  Alcohol  interferes  with  this  test.  Phenol,  even 
in  very  small  amounts,  has  a  characteristic  odor. 

Chloral  Hydrate. — Nessler's  reagent.  A  few  drops  of  Nessler's 
reagent  added  to  a  chloral  hydrate  solution  produces  a  precipitate 
resembling  red  brick  dust,  and  later  this  assumes  a  green  color. 
The  odor  of  chloral  hydrate  is  characteristic,  reminding  one  of  the 
odor  of  the  American  green  walnut.  Chloral  fiends  are  some- 
times diagnosticated  as  diabetes  patients,  as  the  urochloralic  acid 
of  the  urine  reduces  alkaline  copper  solutions. 

Cocain. — Aqueous  solution  of  chromic  acid  (5-percent),  concen- 
trated hydrochloric  acid.  To  "x"  add  a  few  drops  of  the  chromic 


DETECTION   OF   THE    COMMON   POISONS.  91 

acid  solution.  Each  drop  will  produce  a  precipitate,  which  will 
immediately  disappear  if  the  solution  is  shaken.  Then  add  to  this 
clear  solution  y2  dram  of  the  hydrochloric  acid.  A  delicate  orange- 
yellow  precipitate  indicates  cocain. 

Copper. — All  copper  solutions  are  not  blue  or  green,  as  is  the 
common  belief.  If,  however,  clean  platinum  wire  is  moistened  with 
such  solution  and  held  in  the  colorless  flame,  the  latter  will  become 
intensely  green. 

Ergot. — The  chemistry  of  ergot  is  still  unsatisfactory.  Feeding 
ergot  to  chickens  causes  gangrene  of  their  combs,  but  this  method  is 
of  little  value  when  a  quick  diagnosis  is  desired. 

Formalin. — In  amount  sufficient  for  suicidal  purposes,  the  odor 
is  too  characteristic  to  be  mistaken,  and  experimental  evidence 
shows  that  a  large  amount  is  necessary  to  kill.  For  its  detection  in 
milk  see  Milk  and  Its  Home  Modifications,  page  134. 

Hydrocyanic  Acid. — The  odor  of  hydrocyanic  acid  resembles 
that  of  peach  blossoms,  and  is  too  characteristic  to  render  necessary 
further  means  for  identification.  The  poison  is  very  volatile,  and 
must  be  tested  at  the  earliest  moment.  It  should  not  be  inhaled 
in  appreciable  quantities. 

Lead  Acetate  (Authors'  Method). — Dilute  nitric  acid,  concen- 
trated sulphuric  acid.  Sugar  of  lead  has  a  sweetish,  astringent 
taste.  It  shows  a  tendency  to  form  a  milky  solution,  and  contains 
undissolved  crystals.  Add  just  enough  of  the  dilute  nitric  acid 
to  clear  the  cloudy  solution,  and  then  add  1  or  2  drops  of  the  con- 
centrated sulphuric  acid.  The  heavy  white  precipitate  is  lead 
•  sulphate. 

In  case  "x"  can  not  be  cleared  by  a  few  drops  of  the  dilute 
nitric  acid,  add  1  drop  of  the  latter  to  another  sample  of  the 
unknown,  filter,  and  test  this  filtrate  with  the  sulphuric  acid. 

Barium  and  strontium  may  respond  to  the  same  test,  but  usually 
need  not  be  considered.  In  case  their  presence  is  possible,  barium 
will  impart  to  the  colorless  flame  a  yellowish  green  and  strontium 
will  show  a  brilliant  red. 

Lead  in  Drinking  Water. — (See  Some  Simple  Water  Analyses, 
page  140.) 

Mercury  Salts. — Aqueous  stannous  cklorid  solution.  Add  to 
"x"  some  of  this  reagent.  A  gray  and  white  precipitate  indicates 
mercury,  being  a  mixture  of  quicksilver  and  calomel.  The  test 
depends  on  precipitate  formation.  Many  of  these  precipitates  are 


92  LABORATORY    METHODS. 

alcohol  soluble,  and  one  should  be  mindful  of  the  possible  presence 
of  alcohol  in  all  suspected  material.  For  example,  to  prove  that 
the  stomach  washings  of  a  drunkard  contained  corrosive  sublimate, 
it  might  be  necessary  to  heat  them  slightly  to  cause  the  evaporation 
of  the  alcohol,  or  else  to  add  an  excess  of  the  tin  solution. 

Morphin  and  Opium. — Ferric  chlorid  solution.  Add  to  "x"  a 
few  drops  of  this  reagent.  If  the  color  is  obscured  by  a  precipi- 
tate, filter  it.  A  deep-blue  color  indicates  pure  morphin,  while  the 
presence  of  opium  is  shown  by  a  beautiful  dark-red.  In  case  there 
is  any  doubt,  compare  with  a  filtered  solution  of  "x,"  with  the 
reagent,  or  with  controls. 

Phosphorus. — Suicide  with  match  heads  has  become  obsolete. 
At  least  four  are  necessary  to  produce  death  in  an  adult,  unless 
oils  or  fats  have  been  taken.  The  odor  and  phosphorescence  in 
the  dark  are  characteristic.  It  has  been  claimed  that  some  rat 
poisons  contain  phosphorus  in  addition  to  arsenic. 

Silver  Nitrate. — This  turns  black  when  exposed  to  light.  It  is 
precipitated  from  its  solution  by  common  salt  as  insoluble  silver 
chlorid.  Lead  or  mercury  may  answer  this  test,  but  either  may  be 
otherwise  identified  and  differentiated. 

Strychnin. — Concentrated  sulphuric  acid,  crystal  of  potassium 
bichromate.  On  a  white  background — a  piece  of  paper — lay  a 
clean  slide.  On  this  dissolve  some  of  "x"  in  2  drops  of  concen- 
trated sulphuric  acid,  and  in  this  mixture  crush  with  a  glass  rod 
a  crystal  of  potassium  dichromate.  A  beautiful  violet  or  blue 
color  indicates  strychnin.  Very  small  amounts  of  the  drug  are 
bitter  to  the  taste.  Some  of  the  sample  injected  with  a  hypodermic 
needle  into  a  frog  or  other  animal  may  bring  on  the  typical  tonic 
convulsions. 

Sulphonal,  Trional,  Etc. — Either  drug  heated  in  a  dry  test  tube 
with  powdered  wood  charcoal  develops  a  characteristic  odor — 
ethyl  mercaptan.  If  this  odor  is  not  familiar  to  the  physician,  he 
should  run  a  control  test,  using  sulphonal  instead  of  "x. " 

Less  Frequently  Applied  Tests. — Other  substances,  the  descrip- 
tions of  whose  detection  have  been  left  to  larger  books,  may  be 
named  as  follows:  anilin  compounds,  nicotin,  aconite,  veratrin, 
codein,  oxalic  acid,  santonin,  so-called  ptomain  poisonings,  etc. 

Difficulties  and  How  to  Avoid  Them. — One  of  the  most  com- 
mon causes  of  poor  results  in  chemical  analyses  is  working  with 
the  wrong  reagent,  and  this  is  not  always  the  fault  of  the  worker. 


DETECTION    OF   THE    COMMON   POISONS.  93 

Too  many  registered  pharmacists  have  forgotten  their  chemistry, 
and  examination  of  certain  solutions  supposed  to  be  standardized 
by  an  expert  pharmacist  showed  that  no  such  work  had  been  done. 
One  of  the  authors  was  unable  to  obtain  the  diazo  test  in  four  cases 
which  he  knew  to  be  typhoid,  and  an  examination  of  his  sulphanilic 
solution  showed  a  50-percent  sulphuric  acid.  Too  much  must  not 
be  taken  for  granted. 

Nomenclature  is  often  confusing.  Neither  chromic  acid  nor  car- 
bolic acid  is  properly  named.  Glycerin  is  constantly  referred  to 
by  some  druggists  as  a  sugar,  but  is  really  an  alcohol.  Quicksilver 
contains  no  silver,  but  is  metallic  mercury.  These  terms  have  not, 
however,  been  avoided  in  this  book,  as  their  use  is  too  widespread. 

A  case  is  known  where,  in  testing  for  lead  by  the  iodides,  a 
worker,  usually  careful,  thoughtlessly  employed  lead  iodid.  For 
cautions  against  explosives  and  incompatibilities,  see  Laboratory 
Prophylaxis,  page  180. 

It  is  impossible  in  a  book  of  this  scope  to  teach  the  principles  of 
chemical  analysis,  but  the  following  general  rules  may  prove  of 
value  to  the  man  expecting  good  results : 

1.  Absolute  cleanliness.     Test  tubes  can  not  be  kept  too  clean. 
Sugar  of  lead  is  especially  prone  to  adhere  to  glassware.     Do  not 
touch  with  your  fingers  chemically  pure  reagents,  but  pour  directly 
from  their  bottles  into  solvent  or  on  clean  paper,  and  then  cork 
the  bottle  tightly.     Never  lay  a  cork  or  stopper  on  a  table,  but  hold 
between  fingers  until  it  can  be  replaced. 

2.  Allow  time  for  a  reaction  to  take  place  before  adding  more 
reagent  or  deciding  on  a  negative  result.     It  can  not  always  be 
explained  why  the  same  test  may  at  different  times  employ  more 
time. 

3.  If  precipitates  interfere  with  a  color  reaction,  filter  and  ex- 
amine the  filtrate. 

4.  Before  performing  the  Marsh  test,  study  well  the  properties 
of  hydrogen,  how  it  is  generated,  and  how  handled. 

5.  Unless  a  worker  is  certain  of  his  technic,  a  control  test  should 
be  used  in  connection  with  each  investigation.     Many  shortcom- 
ings may  thus  be  detected  which  would  otherwise  escape  observa- 
tion. 

Value  and  Limitation  of  These  Investigations. — These  have  been 
pointed  out  in  the  matter  preceding  the  tests. 


CHAPTER  VIII. 

EXUDATES  IN  BRIEF. 
Apparatus.— 


1.  Centrifuge. 

2.  Eosin. 

3.  Exploratory  needle. 

4.  Formalin. 


5.  Glycerin. 

6.  Microscope   and   accessories. 

7.  Potassium  hydrate. 

8.  Sodium  citrate. 


Obtaining  an  Exudate. — An  ordinary  hypodermic  outfit  may 
sometimes  be  used,  but  it  is  advisable  to  employ  a  long  and  stout 
exploratory  needle.  All  apparatus  should  be  sterile,  especially  if 
any  cultures  are  attempted.  A  small  amount  of  the  fluid  suffices 
for  the  tests  described  in  this  book,  but,  as  larger  amounts  are  often 
removed  for  therapeutic  purposes,  it  would  not  be  a  waste  of  time 
to  take  the  specific  gravity,  or  even  attempt  other  examinations 
described  in  the  larger  volumes.  A  bacteriological  culture  may  be 
easily  made,  but  usually  is  not  necessary  for  safe  conclusions.  If 
apparatus  is  sterile,  any  germ  may  be  looked  upon  with  suspicion, 
but  the  authors  have  often  been  able  to  gain  more  from  a  study  of 
the  cells  than  from  a  search  for  specific  microorganisms.  A  safer 
plan  is  to  investigate  both.  An  ethyl  chlorid  spray  will  render 
these  operations  painless. 

Thoracic  Puncture. — The  spot  selected  for  pleuritic  effusions  is 
marked  by  the  junction  of  the  axillary  line  with  the  seventh  inter- 
costal space,  and  is  clearly  shown  in  Fig.  25.  The  arm  is  raised  and 
the  hand  placed  on  the  opposite  shoulder  in  order  to  widen  the 
interspaces.  The  relation  of  the  intercostal  artery  to  the  lower  edge 
of  the  rib  must  be  kept  in  mind.  Pericardial  puncture  is  rarely 
attempted  outside  of  the  hospital.  The  technic  may  be  found  in  the 
larger  books. 

Abdominal  Puncture. — The  spot  varies,  but  is  usually  low.  A 
short  needle  is  desirable,  so  that  the  bowels  may  not  be  punctured. 

Lumbar  Puncture. — A  short,  strong  sterilized  needle  is  employed, 


References. — Gruner :    Puncture    Fluids;    all    works    on    clinical    diagnosis,    including 
Salili,  Wood,  Boston,   Simon,  etc. 

94 


EXUDATES   IN   BRIEF. 


95 


but  no  syringe  should  be  used  unless  its  plunger  has  been  previously 
drawn.  The  patient  should  lie  on  the  left  side,  with  the  thighs 
flexed  and  shoulders  bent  forward.  A  line  joining  the  iliac  crests 
passes  between  the  third  and  fourth  lumbar  vertebra.  Select  a 


Fig.  25. — Puncture  of  pleura. 

point  midway  between  the  spinous  processes  of  these  two  bones, 
and  place  the  point  of  the  needle  one-third  of  an  inch  to  the  left 
of  this  point  and  insert.  Fig.  26  illustrates  the  exact  position. 
Allow  the  liquid  to  flow  as  it  will,  and  do  not  aspirate.  If  fluid 
does  not  come,  have  the  patient  strain,  and  it  may  be  necessary  to 
again  insert  the  needle.  The  operator  should  be  certain  that  the 
needle  is  not  clogged  before  attempting  this  procedure.  In  these 
punctures,  as  well  as  all  others  including  thoracic,  abdominal, 
joints,  etc.,  several  precautions  are  emphasized: 
1.  All  apparatus  must  be  sterile. 


96 


LABORATORY    METHODS. 


2.  Avoid  important  structures,  as  nerves,  vessels,  intestines,  blad- 
der, heart,  etc. 

3.  Do  not  aspirate  in  lumbar  punctures.     If  necessary  to  carry 
out  this  procedure  elsewhere,  do  so  very  slowly  and  then  permit  ex- 
cess to  drain. 


.Fig.  26. — Diagram  showing  site  of  lumbar  puncture.      x,x,  tips  of  spinous  processes;  x', 
point  midway  between  ;  A,  lower  tip  of  spinal  cord ;  B,  ilium. 

4.  If  patient  shows  any  signs  of  collapse,  stop  the  operation  at 
once.  Very  often  these  punctures  may  be  followed  by  a  prompt 
relief  of  symptoms. 

Preparing  an  Exudate. — As  cells  and  bacteria  may  be  difficult  to 
find,  it  is  usually  advantageous  to  centrifugalize  as  with  urine. 
Many  of  these  exudates  sho\v  a  tendency,  however,  to  clot  very 
quickly,  and  to  avoid  this  the  tube  may  be  one-quarter  filled  with 
2-percent  sodium  citrate  solution.  The  following  process  may  then 
be  followed : 

1.  Centrifugalize  sufficiently. 

2.  Remove  with  a  pipette  the  supernatant  citrate  solution. 

3.  Add  an  equal  amount  of  dilute  formalin,  1-percent  aqueous 
solution. 


EXUDATES   IN   BRIEF.  97 

4.  Mix  thoroughly  by  shaking.. 

5.  Permit  to  stand  five  minutes. 

6.  Centrifugalize  sufficiently. 

7.  Remove   sediment   from  beneath   liquid   by   the   method   de- 
scribed   for    urinary    sediments.     (See    The    Urine    in    Disease, 
page  116.) 

8.  Make  spreads,  dry,  and  fix  by  heat;  stain  with  methylene  blue. 
Most  Important  Findings. — Various  chemical  tests  can  hardly 

be  considered  here.     The  cytoanalysis  is  doubtless  the  most  im- 
portant, and  may  be  briefly  given  as  follows : 

1.  Tuberculosis   is   characterized   by  lymphocytes   and   few  red 
cells. 

2.  Tuberculosis  with  secondary  purulent  infection  is  character- 
ized by  a  mixture  of  lymphocytes,  polymorphonuclear  leukocytes, 
and  red  cells. 

3.  An  infection  never  tuberculous,  but  caused  by  the  so-called 
purulent    germs — as    gonococcus,    meningococcus,    pneumococcus, 
streptococcus,   colon  or  typhoid  bacilli,   etc. — is   characterized  by 
absence  of  red  cells  and  lymphocytes,  but  large  numbers  of  poly- 
morphonuclear leukocytes  are  present. 

4.  Ascites,  etc.,  contains  a  few  mesothelial  cells — large  flat  cells, 
with  single  nuclei. 

Searches  may  be  made  for  the  various  microorganisms.  In  case 
fluid  from  the  lumbar  puncture  shows  lymphocytosis,  especially 
without  red  blood  cells,  the  process  may  be  syphilitic  instead  of 
tuberculous.  Age,  history,  and  other  factors  must  be  taken  into 
consideration.  If,  however,  it  contains  only  polymorphonuclear 
leukocytes,  and  these  in  considerable  numbers,  it  may  be  a  menin- 
gococcus infection;  in  fact,  this  organism  may  be  detected  within 
the  pus  cells.  Meningitis  of  an  acute  type  has  been  caused  by 
other  germs,  notably  the  pneumococcus,  gonococcus,  and  typhoid 
bacillus.  A  few  white  cells  may  be  found  in  a  normal  serous  fluid. 

Less  Frequently  Applied  Procedures. — The  practitioner  does  not 
usually  attempt  the  diagnosis  of  general  paresis  by  lumbar 
punctures.  If  he  desires  to  "tap"  the  pericardial  cavity,  complete 
descriptions  of  this  procedure  may  be  found  in  the  larger  books. 
Fluids  from  ovarian  cysts,  spermatocele,  etc.,  offer  little  to  the 
diagnostician. 

Azoospermatism. — Family  sterility  is  due  in  about  two-fifths  of 
all  cases  to  lack  of  spermatozoa  in  the  male.  The  condition  of  azo- 


98  LABORATORY    METHODS. 

ospermatism  can  not  be  diagnosticated  by  a  single  examination,  or 
by  less  than  a  dozen  such  investigations,  to  be  made  monthly. 
Spermatozoa  may  be  absent  from  the  semen  during  certain  dis- 
eases. The  frequent  exposure  to  x-rays  may  cause  a  destruction  of 
all  spermatozoa  and  result  in  a  permanent  sterility.  Spermatozoa 
may  be  present,  but  may  be  dead  at  the  time  of  emission,  falling 
a  prey  within  the  male  to  the  treponema  or  other  injurious  influ- 
ences. Such  germ  cells  are  not  motile,  but,  in  order  to  prove  that 
loss  of  motion  is  not  due  to  chilling,  examination  must  be  made  at 
once,  using  warmed  slides  and  cover  glasses. 

Spermatorrhea. — The  male  germ  cells  may  be  constantly  present 
in  the  urine  of  many  men,  and  is  caused  by  certain  sexual  excesses, 
masturbation,  and  severe  diseases.  The  urine  of  the  female  may 
contain  spermatozoa,  which  exist  as  a  vaginal  contamination  after 
intercourse. 

Proof  of  Rape. — So  far  as  legal  processes  are  concerned,  such 
questions  are  left  to  experts.  The  parents  of  the  girl  may,  how- 
ever, desire  a  private  opinion,  and  they  may  not  wish  to  subject 
the  girl  to  an  examination,  but  may  bring  some  vaginal  secretion 
or  scrapings,  which  may  be  examined  at  once  for  spermatozoa ;  or, 
more  commonly,  a  dry  and  stained  cloth  may  be  submitted.  In 
.case  the  semen  was  pure  and  is  contaminated  by  little  of  the  vaginal 
secretion,  the  stain  will  be  almost  colorless,  and  will  give  the  cloth 
a  "feel"  not  unlike  that  of  starched,  but  unironed,  linen.  The 
characteristic  odor  may  be  present. 

Place  a  small  piece  of  the  stained  cloth  in  a  few  drops  of  a  1-per- 
cent aqueous  solution  of  caustic  potash,  and  allow  to  soak  for  at 
least  two  hours.  Pour  off  liquid  and  add  several  drops  of  gly- 
cerin. Tease  thoroughly,  but  gently,  as  the  tails  are  very  easily 
broken.  Add  1  drop  of  eosin  and  mix  thoroughly.  Examine  some 
of  the  liquid  under  oil  immersion  lens.  The  spermatozoa  are 
stained  red,  but  cotton  and  linen  fibers  are  unstained.  Other  cells, 
especially  erythrocytes,  take  this  stain,  and  should  be  identified 
if  they  are  present.  They  may  have  been  destroyed  in  the  soaking 
process.  A  vigorous  search  should  be  made  for  the  tails  of  the 
spermatozoa. 

Vaginal  Blenorrhea. — Xoninfectious  leucorrhea  may  be  caused 
by  sexual  excesses,  dysmenorrhea,  and  many  other  conditions  not 
uncommon  to  feminine  physiology,  as  well  as  by  tumors,  malposi- 
tion of  the  uterus,  etc.  So  far  as  macroscopical  findings  are  con- 


EXUDATES   IN    BRIEF.  99 

cerned,  this  discharge  may  resemble  true  pus;  microscopically  it 
may  contain  polymorphonuclear  leukocytes,  and  then  a  vaginitis 
may  be  diagnosticated. 

Purulent  Leucorrhea. — Under  this  head  are  not  usually  included 
the  nonspecific  forms  of  vaginitis,  but  only  those  in  which  the 
gonococcus  may  be  demonstrated.  (See  Searching  for  Germs, 
page  48.) 

Dental  Caries. — In  certain  chronic  diseases  and  in  fevers  the 
saliva  may  become  acid,  and  at  other  times  an  alkaline  reaction  may 
occur.  A  persistent  acidity  is  usually  due  to  lactic  acid,  which  is 
formed  by  certain  bacteria,  which  often  results  in  cavity  formation. 
Phenolphthalein  solution  rather  than  litmus  should  be  used  as  an 
indicator. 

Mercurial  Ptyalism. — Salivation  may  be  due  to  many  causes. 
Mercury  may  be  detected  in  the  saliva  according  to  tests  described 
on  page  91. 

Noguchrs  Butyric  Acid  Test  for  Syphilis. — Noguchi  found  that  the 
active  lipotropic  bodies  causing  the  Wascermann  reaction  were  con- 
tained in  or  at  least  precipitated  with  globulin;  and  that  the  globulin  fraction 
is  increased  in  syphilis.  To  detect  this  increase,  he  has  devised  the  butyric 
acid  test.  This  may  be  applied  to  the  cerebro-spinal  fluid  as  follows: — In  a 
very  small  test  tube,  3  or  4  drops  of  this  fluid  are  mixed  with  ten  drops  of 
a  ten-percent  butyric  acid  solution  in  physiologic  salt  solution.  This  mix- 
ture is  heated  over  a  flame  and  is  boiled  for  a  brief  period.  Two  drops  of 
a  normal  solution  of  sodium  hydrate  are  then  added  quickly  to  the  heated 
mixture,  and  the  whole  boiled  once  more  for  a  few  seconds.  The  cerebro- 
spinal  fluid  employed  must  be  free  from  blood. 

Within  two  hours,  a  white  and  granular  precipitate  should  appear  which 
will  settle  to  the  bottom  of  the  tube.  The  greater  the  amount  of  protein, 
the  more  quickly  the  reaction  will  occur.  Any  precipitate  which  forms  after 
two  hours  may  be  ignored. 

Interpretation  of  the  Butyric  Acid  Test. — This  reaction,  though 
valuable  in  the  diagnosis  of  the  syphilitic  and  parasyphilitic  affec- 
tions, may  occur  in  any  of  the  acute  inflammatory  conditions  of  the  meninges 
and  in  tuberculous  meningitis.  However  all  of  these  may  be  readily  differ- 
entiated at  least  from  the  parasyphilitic  affections  where  acute  symptoms 
and  fever  are  usually  absent.  The  butyric  acid  test  has  been  found  to  be 
present  in  poliomyelitis.  Normal  cerebro-spinal  fluid  may  give  a  slight  tur- 
bidity but  never  a  granular  precipitate  within  two  hours.  The  test  is 
scarcely  as  delicate  as  the  Wassermann  in  its  positive  phase;  but  the  nega- 
tive butyric  acid  test  in  the  diagnosis  of  syphilitic  and  parasyphilitic  condi- 
tions, is  much  more  reliable  than  the  negative  Wassermann  or  Perutz  (see 
pace  199)  :  the  former  excludes  syphilis,  but  the  latter  do  not.  In  case  the 
Perutz  test  is  negative,  the  butyric  acid  test  should  be  carried  out.  A  nega- 
tive butyric  acid  test  almost  excludes  the  possibility  of  true  tabes  or  general 
paralysis. 

The  reaction  is  also  of  value  in  differentiating  between  the  various  forms 
of  acute  meningitis  and  the  other  infectious  diseases.  Thus  in  typhoid, 
typhus,  malaria  and  the  exanthemata,  the  reaction  is  negative. 


CHAPTER  IX. 
DIAZO  VERSUS  WIDAL. 

This  chapter  is  designed  to  set  aright  the  puzzled  practitioner, 
and  it  is  probable  that  many  of  the  recommendations  would  hardly 
find  favor  with  hospitals  or  college  clinics.  Were  it  not  for  the 
purpose  of  comparison,  these  two  investigations  would  be  included, 
respectively,  in  The  Urine  in  Disease  and  Searching  for  Germs. 

EHRLICH'S  DIAZO  REACTION. 

Advantages  in  the  Bedside  Diagnosis  of  Typhoid. — These  ad- 
vantages are  as  follows : 

1.  It  occurs  early — that  is,  when  a  final  diagnosis  is  important. 
It  is  expected  during  the  first  week,  and  it  is  often  seen  from  the 
third  to  the  fourth  day  after  the  onset.     It  is  commonly  observed 
before  the  rash  appears  (Osier).     The  authors  have  noted  its  pres- 
ence in  cases  not  yet  bedfast — that  is,  during  that  period  of  lassi- 
tude, headache,  and  chilly  feeling  which  so  often  precede  the  onset 
proper — and  patients  with  such  symptoms  have  been  sent  from  the 
consultation  room  to  the  sickbed  with  a  fairly  safe  diagnosis. 

2.  The  diazo  test  may  be  easily  and  rapidly  completed  at  the 
bedside,  requiring  three  solutions,  a  test  tube,  and  three  minutes' 
time. 

3.  The  reaction  is  present  in  almost  every  case  of  typhoid. 

4.  The  reaction  is,  in  a  practical  sense,  specific.     It  occurs  in 
other  diseases,  but,  with  the  exception  of  a  few  cases  of  miliary 
tuberculosis,   these  should  rarely  be  confused  with  typhoid.     In 
these  cases  of  acute  miliary  tuberculosis  the  reaction  is  rarely,  if 
ever,  present  during  the  first  week. 

5.  The  diazo  reaction  may  differentiate  between  a  relapse  and  a 
complication  when  all  other  signs  fail,  and  it  often  reappears  be- 
fore or  is  coincident  with  recurrence  of  the  fever,  but  is  not  ob- 


References. — Sahli,    Emerson,    Simon,    Wood,    Boston,    and    other    works    on    clinical 
diagnosis. 

100 


DIAZO   VERSUS   WIDAL.  101 

served  in  connection  with  appendicitis,  perforation  of  the  gut,  or 
in  iliac  thrombosis. 

Disadvantages  of  the  Diazo. — Ehrlich's  test  is  not  without  its 
shortcomings,  as  here  noted: 

1.  It  is  not  absolutely  pathognomonic. 

2.  Unfortunately  the  diazo  reaction  is  not  always  present.     A 
negative  test  does  not  imply  that  the  disease  is  not  enteric  fever, 
but  the  percentage  of  cases  in  which  the  diazo  is  really  absent,  must 
be  small  indeed. 

Technic  of  the  Diazo  Reaction. — The  following  apparatus  and 
reagents  are  necessary. 

Solution  1 — sulphanilic  acid ;  saturated  solution  in  5-percent 
hydrochloric  acid. 

Solution  2. — sodium  nitrite;  i/o-percent  aqueous  solution. 

Solution  3 — aqueous  ammonia. 

Test  tube. 

Medicine  dropper. 

The  three  solutions  may  be  obtained  from  reliable  manufacturers. 
Put  51  drops  of  urine  in  a  test  tube  and  add  50  drops  of  solution 
1  and  1  drop  of  solution  2.  Shake  thoroughly.  Then  add  quickly 
about  5  drops  of  ammonia,  allowing  it  to. run  down  the  side  of  the 
test  tube  in  such  a  manner  as  to  form  an  upper  layer.  If  the  test 
is  positive,  a  deep-pink  or  rose-red  colored  ring  will  appear  at  the 
junction  of  the  liquids.  Shake  the  mixture.  The  entire  bulk  and 
also  the  foam  should  become  red,  the  coloration  of  the  foam  being 
most  characteristic  of  the  reaction.  If  the  urine  is  allowed  to 
stand  until  the  next  visit,  a  dark  bile-green  sediment  may  be 
present,  and,  while  of  value,  its  absence  does  not  indicate  a  nega- 
tive test.  The  authors  observed  one  case  in  which  this  precipitate 
was  formed  immediately  on  the  addition  of  the  ammonia  and  be- 
came very  dense  after  one-half  hour.  A  pink  color  which  formed 
at  first  was  not  detected  fifteen  minutes  later.  The  patient  was 
delirious  at  the  time,  but  eventually  recovered.  No  satisfactory 
explanation  of  this  phenomenon  was  ever  proposed. 

Pseudo-Diazo  Reactions. — In  health,  salmon-  or  orange-colored 
rings  may  be  observed,  but  not  the  characteristic  pink  or  rose-red 
colors.  The  foam  is  not  colored,  and  the  green  precipitate  fails  to 
form.  Where  large  amounts  of  urine  are  passed,  the  causative 
factor  may  be  so  diluted  that  a  positive  reaction  is  obtained  with 
difficulty,  or  not  at  all. 


102  LABORATORY    METHODS. 

Salol,  betanaphthol,  and  opium,  when  administered,  may  cause  a 
pseudo-reaction.  The  foam  is  not,  however,  pink  or  red,  but  is 
colorless  or  yellow,  and  the  green  precipitate  never  forms.  Bis- 
muth subgallate  and  the  tannic  acid  derivatives  prevent  the  posi- 
tive diazo  reaction  from  appearing,  and  it  is  due  largely  to  failure 
to  take  this  into  consideration  that  the  total  percentage  of  positive 
tests  is  held  lower  than  is  really  just.  If  jaundice  is  present,  a 
dark,  cloudy  discoloration  may  obscure  the  true  reaction. 

In  certain  cases  of  pneumonia,  which  may  or  may  not  simulate 
typhoid,  a  yellow  color  may  appear  on  the  addition  of  solution  2. 
Ammonia  changes  this  to  a  lemon  tint.  Such  a  reaction,  "egg 
yellow, ' '  is  said  to  have  been  observed  in  cases  of  typhoid  fever. 

In  certain  affections,  as  erysipelas,  rheumatism,  and  other  dis- 
eases not  easily  confounded  with  true  typhoid,  the  true  diazo  has 
been  observed. 

Modifications  or  Substitutions  for  Diazo  Reaction. — These  are 
listed,  but  not  described  in  detail. 

1.  GREENE'S  MODIFICATION.     The  test  is  said  to  be  more  delicate 
when  double  the  amount  of  solution  1  is  used.     With  this  modifi- 
cation the  same  amounts  of  the  other  reagents  are  used. 

2.  FRIEDENWALD 's    SUGGESTION.     Paramidoacetophenon    is    sub- 
stituted for  the  sulphanilic  acid. 

3.  EHRLICH'S  MODIFIED  DIAZO.     Where  dimethylaminobenzalde- 
hyde  and  other  reagents  are  employed.  (See  page  114.) 

4.  Russo's  REACTION.1     Where  methylene  blue  is  used. 
Sources  of  Error  in  Technic. — These  are  few,  but  important. 

The  instructions,  if  followed  minutely,  may  be  depended  upon. 
One  of  the  most  frequent  causes  of  difficulty  may  be  traced  to 
adding  the  ammonia  layer  too  slowly.  When  this  occurs,  the  re- 
action may  not  take  place.  Other  sources  of  error  may  be  recog- 
nized by  a  careful  study  of  the  pseudo-reactions. 

Value  and  Limitations  of  the  Diazo  Test. — From  what  has  been 
said,  the  value  of  this  reaction  may  be  summed  up  about  as  follows : 
With  certain  limitations,  it  is  especially  useful  as  a  bedside  diagnos- 


1  This  is  a  simple  and  seemingly  valuable  method  of  differentiating  between  typhoid 
fever  and  acute  miliary  tuberculosis.  The  urine  of  the  former  will  be  turned  a  beau- 
tiful emerald  color  when  4  drops  of  a  1  :1,000  aqueous  solution  of  methylene  blue  are 
added  to  4  or  5  cc.  of  the  sample.  In  the  latter  disease  only  a  bluish  or  greenish 
tinge  is  obtained.  It  is  advisable  to  use  a  normal  urine  in  a  control  test  if  there  is 
any  question  in  regard  to  the  color  changes.  As  the  positive  reaction  occurs  in  other 
pathological  conditions,  it  is  valuable  only  in  the  differentiation  named,  and  should 
always  be  used  in  connection  with  the  diazo. 


DIAZO   VERSUS   WIDAL.  103 

tic  procedure,   and   these   circumscriptions  have  been  emphasized 
under  disadvantages,  errors,  pseudo-reactions,  etc.    • 

WIDAL  REACTION. 

Widal  Reaction  Defined. — While  typhoid  agglutination  tests  in 
general  are  considered,  the  technic  described  will  deal  only  with 
the  suspensions  of  dead  cultures  and  with  macroscopic  observations. 
These  seem  to  be  not  only  sufficiently  reliable  procedures,  but  are 
specially  adapted  to  bedside  work,  and  the  original  test  could  hardly 
be  made  except  with  the  equipment  of  the  large  laboratory. 

Advantages  of  the  Widal  Test. — These  advantages  are  as  fol- 
lows: 

1.  It  is  pathognomonic  of  enteric  fever,  thus  differentiating  it 
from  acute  miliary  tuberculosis. 

2.  May  occur  in  those  few  cases  where  the  diazo  test  is  absent, 
though  not  usually  so  early. 

3.  Its  appearance,  even  if  too  late  for  diagnosis  so  far  as  treat- 
ment is  concerned,  serves  to  complete  hospital  records,  death  cer- 
tificates, vital  statistics,  etc.     The  reader  must  not  infer  that  the 
Widal  is  invariably  a  late  reaction. 

Disadvantages  of  the  Widal  Test. — These  disadvantages  are  as 
follows  : 

1.  It  is  of  little  or  no  prognostic  value  because  it  does  not  vary 
or  reappear  with  a  relapse,  and  can  not  therefore  differentiate  it 
from  serious  complications. 

2.  Takes  too  much  time  to  perform.     Even  with  the  simple  tech- 
nic described,  a  diagnosis  must  be  delayed  for  at  least  a  few  hours 
— a  long  time  when  we  consider  that  we  are  dealing  with  an  acute 
disease. 

3.  Although  sometimes  present  on   the   fourth   day,   it  usually 
appears   late.     Some    observers    (Stitt   and   the   authors)    do   not 
recommend  it  as  a  routine  procedure  until  the  second  week. 

4.  It  is  not  always  present  in  true  typhoid.     Although  it  usually 
appears  at  some  stage  of  enteric  fever,  its  invariable  presence  in 
this  disease  has  yet  to  be  proven,  and  a  negative  reaction  does  not 
imply  no  typhoid.     So  far  as  percentage  is  concerned,  one  thing 
is  certain — during  the  early  manifestations  of  the  disease,  when 
diagnosis  from  a  therapeutic  standpoint  is  most  important,  the 


104  LABORATORY    METHODS. 

diazo  reaction  occurs  in  much  higher  proportion  of  all  cases  than 
does  the  agglutination  test. 

Technic  of  the  Widal. — The  general  practitioner  should  appre- 
ciate the  efforts  of  certain  manufacturers  in  providing  the  simpli- 
fied Widal  test,  but  the  authors  do  not  recommend  the  expensive 
outfit.  The  manufacturers  are  usually  willing  to  supply  the  dead 
cultures  of  the  typhoid  bacilli,  properly  preserved  and  suspended, 
without  the  fancy  pipettes,  etc.  The  remainder  of  the  apparatus 
consists  of  two  homeopathic  vials. 

The  technic  is  not  complex.  Add  about  1  dram  of  the  suspen- 
sion to  each  vial.  One  of  these  is  corked  and  serves  as  a  control. 
Into  the  other  add  2  or  3  drops  of  the  patient's  blood  directly 
from  a  finger  prick.  Shake  and  cork.  Set  aside  both  vials  and 
examine  in  several  hours.  These  bottles  can  not  be  carried  in  the 
pocket  without  interfering  with  the  test,  so  that,  unless  the  physi- 
cian 's  office  is  near,  a  return  call  is  necessary.  Caution  the  family 
not  to  touch  the  vials.  A  positive  test  is  observed  when  the  sus- 
pension becomes  granular  or  milky  and  the  germs  sink  to  the 
bottom,  leaving  an  upper  clear  fluid.  The  control  should  remain 
cloudy. 

Bass  and  Watkins'  Rapid  Method  for  Widal. — The  blood  is 
diluted  by  dissolving  it  in  approximately  four  times  its  volume 
of  water.  Then  one  or  two  drops  of  this  diluted  blood  are  mixed 
on  a  microscopic  slide  or  other  piece  of  glass  with  an  equal  quan- 
tity of  the  suspension  of  dead  typhoid  bacilli.  The  slide  is  tilted 
from  side  to  side  or  end  to  end  in  order  to  keep  the  mixture 
flowing  back  and  forth.  If  the  reaction  is  positive,  a  grayish- 
mealy  sediment  appears  within  one  minute,  usually  much  more 
quickly.  This  consists  of  agglutinated  bacilli  and  is  easily  seen 
with  the  unaided  eye.  It  appears  in  the  fluid  around  the  edges 
first,  and  tends  to  collect  there.  If  the  agglutination  is  contin- 
ued, the  clumps  increase  in  size  for  two  or  three  minutes.  With 
blood  giving  a  weak  reaction,  the  appearance  of  the  sediment  is 
not  so  rapid  as  with  stronger  reacting  blood.  It  is  useless,  how- 
ever, to  continue  the  test  longer  than  two  minutes,  for,  if  the  re- 
action has  not  occurred  within  that  time,  it  will  not  ensue  at 
all.  When  the  reaction  is  negative,  no  agglutination  occurs;  and 
the  mixture  remains  as  clear  and  unchanged  as  when  placed  upon 
the  slide.  The  suspension  is  best  made  up  containing  ten  thou- 


DIAZO    VERSUS   WIDAL. 


105 


sand  million  dead  typhoid  bacilli  per  cc.  in  1.7  percent  sodium 
chloride  solution  to  which  one  percent  of  formalin  has  been 
added.  Keep  well  stoppered  in  an  amber  bottle  and  in  a  dark 
place. 

Table  of  Comparisons. — It  will  be  observed  that  this  chapter 
has  been  writtenffor  the  needs  of  the  general  practitioner,  and  the 
comparative  table  given  below  has  been  prepared  with  the  same 
object  in  view,  T-yphoid  is  an  acute  and  dangerous  disease.  Cor- 
rect therapeutic  measures  must  be  instituted  promptly,  and  delays, 
unless  made  necessary  by  submitting  specimens  to  distant  labora- 
tories, must  be  avoided.  The  technic  and  significance  of  these  re- 
actions are  so  simple  that  the  attending  physician  has  only  him- 
self to  blame  if  his  patient  dies  "waiting  for  a  diagnosis." 


DIAZO. 

1.  Appears  early  in  typhoid   fever. 

2.  Reappears   with   relapses,   but   not 

with  complications. 

3.  Technic   rapidly  completed. 

4.  Does    not   differentiate    acute    mil- 

iary  tuberculosis;  when  delayed 
until  the  third  week,  suggests 
tuberculosis  of  a  general  type. 

5.  Not  always  present. 

6.  Occurs  in  other  diseases  not  easily 

confused  with  typhoid. 


WIDAL. 

1.  Appears  in  typhoid  fever. 

2.  Relapses  do  not  influence  the  test. 

3.  Technic  in  simple  form  takes  se-v- 

eral  hours. 

4.  Not   present   in   acute   miliary   tu- 

berculosis. 


5.  Not  always  present. 

6.  Occurs  in  no  other  disease. 


The  authors  have  no  intention  to  detract  from  the  Widal  test, 
but  simply  desire  to  classify  it  properly  and  then  to  emphasize 
those  advantages  of  the  diazo  reaction  usually  overlooked  or  neg- 
lected. The  physician  may  make  both  tests,  but  should  not  omit 
the  diazo. 

Less  Frequently  Applied  Procedures. — Both  the  microscopic 
and  macroscopic  tests  with  the  living  bacilli  are  best  conducted  by 
the  larger  laboratories,  but,  in  spite  of  emphatic  statements  to  the 
contrary,  these  seem  to  possess  no  special  advantages  over  the  test 
here  described. 


106 


LABORATORY   METHODS. 


CHAPTER  X. 


THE  URINE  IN  DISEASE. 

Apparatus. — Does  not  include  that  used  in  the  urobilinogen 
test. 


1.  Nitric  acid,   concentrated. 

2.  Centrifuge          or          sedimentation 

glasses. 

3.  Ferric  chlorid   solution,   strong. 

4.  Graduate. 

5.  Haines'   solution. 

G.  Lead   acetate   solution,   strong. 

7.  .Medicine  dropper. 

8.  Microscope  and  accessories. 


9.  Phenolphthalein,     1-percent     alco- 
holic solution. 

10.  Pipette,  long. 

11.  Silver  nitrate  solution,  15-percent. 

12.  Saccharimeter    (Einhorn). 

13.  Squibb's  urea  apparatus. 

14.  Uririometer. 

15.  Window  glass,  2x2  inches. 


Scope  of  This  Chapter. — It  has  been  the  aim  of  the  authors  to 
select  the  best  tests,  and  to  describe  them  simply,  but  thoroughly, 
with  a  view  to  assist  the  physician  who  must  do  his  work  hurriedly 
and  who  must  often  search  through  dozens  of  methods  to  find  the 
one  which  he  may  properly  apply  without  laboratory  luxuries  and 
one  upon  which  he  may  safely  depend.  In  many  cases  a  diagnosis 
without  urinalysis  is  valueless,  but,  on  the  other  hand,  it  may  be 
stated  that  "conclusions  drawn  from  the  wrater  alone  are  as  brittle 
as  the  urinal  containing  it." 

Amount,  Significance,  Etc. — The  normal  amount  varies  from  30 
to  45  ounces  every  twenty-four  hours,  and  the  normal  and  patho- 
logical variations  bear  the  following  indications : 

Increase  of  Urine.  Due  to  cold,  diabetes,  amyloid  kidney,  inter- 
stitial nephritis,  some  brain  tumors,  and  following  fever. 

Decrease  of  Urine  (not  Including  Anuria).  Due  to  hot  weather 
and  perspiration,  parenchymatous  nephritis,  diarrhea,  hysteria, 
and  during  fevers. 

Specific  Gravity,  Significance,  and  Estimation. — This  varies 
normally  between  1.012  and  1.025,  being  high  or  low  respectively 


References. — Memminger:  Diagnosis  by  the  Urine;  Tyson:  Examination  of  the  Urine; 
Saxe:  Examination  of  the  Urine;  Rieder:  Urinary  Sediments;  all  works  on  clinical 
diagnosis,  especially  Sahli,  Boston,  Simon,  Wood,  etc. 

107 


108  LABORATORY   METHODS. 

as  there  is  little  or  much  urine  passed  daily.  In  parenchymatous 
nephritis  it  is  high,  and  there  is  little  urine;  in  diabetes  there  is 
polyuria,  but  a  high  specific  gravity ;  in  insipid  diabetes  and  inter- 
stitial nephritis  there  is  a  persistent  polyuria,  with  a  low  specific 
gravity. 

Estimation  of  the  specific  gravity  by  means  of  the  urinometer, 
when  carefully  done,  is  an  entirely  different  procedure  from  that 
usually  conducted  even  in  a  perfectly  arranged  laboratory.  A 
correct  reading  is  impossible  where  the  following  precautions  are 
overlooked : 

1.  All  foam  should  be  taken  up  from  the  surface  of  the  urine 
by  means  of  a  piece  of  filter  paper  or  blotter  before  the  bulb  is 
immersed. 

2.  The  urinometer  should  float  freely  toward  the  center  of  the 
sample,  and  should  not  be  in  contact  with  the  inner  surface  of  the 
cylinder. 

For  practical  purposes,  temperature  corrections  are  not  neces- 
sary, providing  the  sample  is  neither  very  cold  nor  has  been 
heated. 

Color,  Significance. — The  color  of  normal  urine  varies  from  that 
of  copper  to  brass,  and  the  color  changes  bear  the  following  indi- 
cations : 

Colorless  urine — polyuria ;  red  urine — fresh  blood,  urates ;  brown 
urine — blood,  urates ;  smoky  urine— blood ;  gray  urine — pus,  al- 
bumin ;  blue  urine — indican,  methylene  blue ;  black  urine,  on  stand- 
ing— alkapton  formed  normally  or  after  the  administration  of  aro- 
matic series  of  carbon  Compounds,  the  color  usually  first  appearing 
at  the  top  of  the  sample  and  proceeding  downward. 

Odor,  Significance. — There  is  a  characteristic  normal  odor  due 
to  certain  volatile  organic  substances.  Urotropin  administration 
imparts  to  the  urine  an  odor  of  formaldehyd.  The  sweet  odor  of 
diabetes  needs  no  comment.  A  urine,  standing,  gives  off  odors 
characteristic  of  alkaline  fermentation  (page  121,  122). 

Transparency,  Significance. — A  normal  urine  is  usually  clear, 
but  may  contain  urates  when  voided,  especially  after  exposure  to 
cold,  and  may  contain  amorphous  phosphates  after  a  large  meal. 
A  slight  cloudiness  may  be  due  to  those  small  quantities  of  mucus 
and  cells  normally  present. 

Marked  cloudiness  is  usually  pathological  to  the  fresh  urine.  If 
due  merely  to  salts,  a  little  heat  and  a  drop  of  nitric  acid  will  clear 


THE   URINE   IN    DISEASE.  109 

it.  Pus,  albumin,  and  blood  do  not  disappear  during  the  process, 
and  their  identification  must  be  accomplished  by  other  tests. 

Reaction,  Significance,  and  Determination. — A  slight  acidity  is 
normal.  A  slight  alkalinity  can  not,  in  many  cases,  be  termed  ab- 
normal. Normal  acidity  is  not  dependent  en,  nor  perhaps  influ- 
enced by,  uric  acid,  but  is  caused  by  certain  phosphates. 

Marked  alkalinity  of  freshly  voided  urine  may  suggest  cystitis, 
but  alkalinity  of  a  decomposing  urine  has  no  clinical  significance. 
A  more  complete  treatment  of  this  subject  is  found  under  the  com- 
parison of  acidemia  and  acidosis  (page  123). 

The  ordinary  litmus  test  is  worse  than  a  waste  of  time  in  prac- 
tical urinalysis.  Acidity  versus  alkalinity  may  be  first  solved  by 
the  more  delicate  indicators,  and  these  serve  not  only  to  draw  finer 
distinctions,  but  actually  give  some  idea  as  to  the  degree  of  the 
reaction.  The  authors  use  a  dilute  solution  of  phenolphthalein, 
such  as  is  employed  in  the  gastric  analyses.  In  acid  or  neutral 
media  this  solution  is  colorless,  but,  if  one  drop  is  added  to  an 
alkaline  solution,  a  prompt  color  reaction  takes  place,  varying  from 
a  light-pink  to  a  deep-crimson,  depending  on  the  degree  of  alka- 
linity. A  simple  method  of  estimating  urinary  acidity  is  as  fol- 
lows : 

Add  to  the  urine  a  drop  of  the  indicator.  A  colorless  solution 
signifies  that  the  urine  is  either  neutral  or  acid.  Now  add  a  drop  of 
the  sodium  hydrate  solution  used  when  determining  the  percentage 
of  total  acid  in  the  gastric  juice  (Chemistry  and  Biology  of  the 
Gastric  Juice,  page  76).  If  the  reaction  was  neutral,  a  pink  or  red 
color  will  appear.  The  acidity  may  be  determined  approximately 
in  degree  by  the  number  of  drops  of  the  alkaline  solution  necessary 
to  impart  to  the  sample  a  permanent  red  color,  and  this  permanency 
can  be  tested  by  stirring  thoroughly.  In  case  exact  readings  are 
desired,  titration  may  be  conducted  as  described  in  Chemistry  and 
Biology  of  the  Gastric  Juice  (page  76). 

Significance  of  Albumin. — The  sources  of  urinary  albumin  are 
many  and  its  etiology  varied,  but  albumin  is  not  expected  to  be 
found  in  a  freshly  voided  normal  urine.  The  following  list  will 
serve  to  give  an  idea  of  the  principal  sources  of  protein  bodies : 

Serum  Proteins  (which  may  or  may  not  cloud  the  voided  urine). 
1,  fevers;  2,  diseases  of  the  blood;  3,  poisonous  drugs;  4,  accom- 
panying heart  disease ;  5,  certain  functional  and  dietetic  types ; 
6,  organic  kidney  lesions. 


110  LABORATORY    METHODS. 

Urinary  Suspensions  of  Cellular  Elements.  1,  pus  or  epithelial 
cells  in  considerable  numbers;  2,  blood  cells;  3,  bacteria. 

Choice  of  Tests. — The  heat  and  nitric  acid  test — not  the  "nitric 
acid  and  heat"  test — when  properly  conducted,  often  suffices,  hut 
can  not  be  recommended  as  the  main  procedure,  nor  as  the  choice  of 
methods  when  only  one  test  is  used,  as  it  will  not  demonstrate 
traces  of  albumin.  The  method  is,  however,  valuable,  and  should 
be  included  mainly  to  rule  out  urates,  which  are  dissolved  by  the 
heat,  and  earthy  phosphates,  which  are  precipitated  by  a  rise  in 
temperature,  but  disappear  on  adding  the  acid.  If  an  efferves- 
cence occurs  on  adding  the  acid,  it  is  due  to  the  formation  of  ni- 
trogen gas  or  carbonic  acid  gas,  depending  upon  the  reaction  of  the 
urine. 

It  is,  however,  the  trace  of  albumin  that  concerns  us  in  diagnos- 
tics, and  this  small  amount,  as  in  diabetes  and  interstitial  nephritis, 
may  mean  much  more  to  the  attending  physician  or  life  insurance 
examiner  than  any  other  single  symptom.  The  first  described 
method  is  merely  a  modification  of  Boston 's  pipette  method,  a  medi- 
cine dropper,  such  as  is  used  by  every  physician,  being  substituted 
for  the  regular  pipette. 

Boston's  Pipette  Method. — Compress  the  bulb  of  a  clean  medi- 
cine dropper  (Fig.  28),  immerse  the  point  in  a  sample  of  the  urine 
and  slightly  relax  the  pressure  on  the  bulb,  when  a  small  quantity 
of  the  urine  will  enter  the  tube.  Carefully  wipe  off  the  outer  sur- 
face of  the  tube,  immerse  the  point  in  a  small  quantity  of  concen- 
trated nitric  acid,  and  again  relax  the  pressure  sufficiently  to  draw 
up  a  column  of  the  liquid.  If  albumin  is  present,  a  distinct  white 
ring  forms  at  the  junction  of  the  liquids.  This  modification  offers 
no  advantage  over  Boston's  method,  except  that  of  a  bedside  di- 
agnosis, where  a  medicine  dropper  and  a  bottle  of  nitric  acid  may 
be  conveniently  used.  It  is  more  simple,  and  at  the  same  time  more 
likely  to  show  the  trace  of  albumin,  than  the  heat  and  nitric  acid 
method,  although  both  tests  should,  if  possible,  be  made. 

Heat  and  Nitric  Acid  Test.— Fill  a  clean  test  tube  half  full  of 
urine  and  boil,  when  a  cloudiness  may  result,  which  may  be  due 
either  to  phosphates  or  to  albumin.  The  addition  of  a  few  drops 
of  nitric  acid  will  clear  the  former,  but  not  the  latter.  In  rare  in- 
stances, calcium  phosphate  may  be  dissolved  with  difficulty. 

Filtration  of  the  Urine. —  Filtration  of  a  cloudy  urine  is  ad- 
visable when  searching  for  traces  of  albumin,  and  will  remove  all 


THE   URINE   IN   DISEASE. 


Ill 


cells  and  most  bacteria.  In  case,  however,  the  physician  is  com- 
pelled to  make  the  examination  at  the  bedside,  he  may  often  omit 
it,  comparing  the  tested  sample  with  one  which  has  not  been  exam- 
ined, and  in  this  way  he  will  be  frequently  able  to  note  marked 


Fig.  28. — Modification  of  Boston's  pipette  test  for  albumin. 


differences  in  the  amount  of  albumin  present.  Tn  other  words, 
while  it  is  advisable  to  use  only  a  clear  urine  when  testing  for 
urinary  albumin,  the  absence  of  such  apparatus  should  not  interfere 
with  making  the  test,  and  it  may  be  possible  to  obtain  in  the  house- 
hold an  ordinary  tin  funnel  and  a  piece  of  paper  suitable  for  the 


112  LABORATORY   METHODS. 

procedure.  Contrary  to  the  general  idea,  the  laity,  as  a  rule,  do 
not  discredit  these  examinations. 

Estimations  of  Albumin. — It  is  indeed  strange  that  the  trace 
of  albumin  is  often  of  greater  prognostic  import  than  the  large 
flaky  or  putty-like  precipitate,  and  for  this  matter  the  reader  is 
referred  to  the  larger  books  for  the  various  albuminometers. 

Sources  of  Error. — It  does  not  necessarily  follow  that  an  al- 
bumin reaction  indicates  a  renal  lesion.  If  the  urine  has  not  been 
filtered,  bacteria  and  the  various  cells  may  cause  the  positive  test 
to  occur.  Pseudo-tests  may  be  observed,  and  should  be  ruled  out 
by  the  following  methods  when  their  presence  is  suspected : 

1.  I) 'rates.     These  quickly  dissolve  when  heated. 

2.  iSantal  Oil,  Copaiba  Oil,  Etc.     A  few  drops  of  alcohol  added  to 
the  urine  quickly  dissolves  these  or  prevents  their  formation. 

Significance  of  Glucose. — Glycosuria  may  be  transient  or  diabe- 
togenous,  and  before  the  latter  diagnosis  can  be  made  the  occur- 
rence of  this  condition  must  be  shown  to  be  persistent,  or  at  least 
to  persistently  recur  even  when  the  carbohydrate  food  is  somewhat 
diminished.  The  presence  of  diacetic  acid  or  of  the  other  acetone 
bodies  signifies  sugar  diabetes.  In  case  of  doubt,  a  record  of 
twenty-four-hour  amounts  and  specific  gravity  tests  may  clear  up 
the  diagnosis.  Glycosuria  is  merely  a  sequence  of  hyperglycemia. 

Detection  of  Glucose. — The  authors  recommend  Haines'  test,  not 
merely  because  it  is  simple,  but  because  it  gives  such  satisfactory 
results.  A  small  bottle  of  the  reagent  may  be  obtained  at  any 
pharmacy,  and  does  not  necessitate  a  fresh  preparation  for  each 
test.  In  time,  however,  a  reddish  precipitate  will  settle  to  the 
bottom  of  the  bottle,  when  a  fresh  supply  should  be  obtained.  On 
boiling  this  reagent,  before  the  urine  is  added,  precipitation  should 
not  occur.  If  albumin  is  present  in  the  sample  to  be  tested,  it 
should  be;removed  previous  to  the  examination.  The  procedure  is 
as  follows : 

1.  Boil  in  a  clean  test  tube  for  two  minutes  1  dram  or  more  of 
Haines'  reagent. 

2.  Hold  in  the  light  to  make  certain  that  no  change  has  occurred. 

3.  Quickly  add  from  2  to  7  drops,  not  more,  of  the  urine. 

4.  Keep  the  reagent  boiling  before  the  urine  is  added,  but  do 
not  heat  after  this  has  been  done. 

5.  A  heavy  yellow,  brown,  or  red  precipitate  indicates  the  pres- 
ence of  glucose.     A  slight  flaky  white  or  dirty  collection  of  crys- 


THE   URINE   IN    DISEASE.  113 

tals  indicate  merely  a  partial  reduction  of  the  reagent,  and  do  not 
indicate  that  glucose  is  present.  The  typical  precipitate  is  heavy, 
both  in  appearance  and  in  reality,  settling  to  the  bottom  of  the  test 
tube  like  sand,  and,  when  once  seen,  is  never  confused  with  the 
pseudo-reactions. 

Estimation  of  Glucose. — This  may  be  necessary  in  certain 
dietetic  tests,  but  certainly  never  as  a  prognostic  procedure,  the 
increase  of  the  acetone  bodies  serving  the  latter  purpose. 

The  Einhorn  saccharimeter  offers  a  method  that  is  simple  and 
fairly  accurate.  Its  chief  objection  is  that  a  wait  of  twenty-four 
hours  or  longer  is  required  for  its  completion,  a  criticism  that 
seems  inconsequential  when  the  chronic  nature  of  diabetes  is  con- 
sidered. 

Sources  of  Error. — Haines'  test  is  satisfactory  when  directions 
are  properly  followed.  Glucosides  and  certain  volatile  oils,  when 
taken  internally,  are  often  excreted  by  the  kidneys.  When  boiled, 
they  break  up  into  simple  substances,  including  either  free  glucose 
or  similar  bodies,  which  would,  of  course,  reduce  Haines'  solution; 
but  these  will  not,  however,  cause  any  trouble  if  the  contents  of  the 
tube  are  not  heated  after  the  urine  is  added.  As  noted  above, 
albumin  will  interfere  with  the  test,  and  should,  if  possible,  be 
precipitated  and  filtered  before  testing  for  glucose.  The  physi- 
cian may  advantageously  at  some  idle  moment  attempt  this  test 
with  a  sample  of  urine  to  which  a  little  glucose  has  been  added. 
A  qualitative  fermentation  test,  with  a  little  yeast  in  an  ordinary 
bottle,  leaves  no  doubt  as  to  the  presence  of  glucose. 

Significance  and  Detection  of  Bile. — Biliary  products,  such  as 
are  finally  excreted  by  the  kidneys,  appear  in  the  urine  as  uro- 
bilin,  and  are  the  cause  of  its  normal  yellow  or  orange  tint.  In 
jaundice,  however,  bilirubin  and  its  oxygenated  derivatives  may  be 
present  in  the  urine.  The  best  test  for  these  may  be  made  by 
merely  shaking  well  the  sample  and  observing  carefully  the  color 
of  the  foam.  In  normal  urine  this  is  white,  but,  if  abnormal  biliary 
pigments  are  present,  a  yellow,  green,  or  brown  coloration  will  be 
noted.  For  practical  purposes  no  other  test  need  be  attempted. 

Significance  of  Blood. — Fresh  or  changed  blood  may  come  from 
any  portion  of  the  urinary  apparatus.  It  is  claimed  that  renal 
and  vesicle  hematuria  may  be  distinguished  by  several  mechanical 
methods.  One  of  these  requires  the  urine  to  stand  twenty-four 
hours  in  a  conical  glass.  In  vesicle  hematuria  all  blood  will  have 


114  LABORATORY   METHODS. 

settled  to  the  bottom  of  the  glass,  but  in  the  renal  forms  the  entire 
liquid  will  remain  smoky.  Fresh  blood  indicates,  most  probably, 
a  vesicle  source.  Casts  containing  blood  cells  point  to  renal  origin. 

A  red  urine  may  be  due  to  fresh  blood  or  to  urates.  Heating 
the  sample  causes  rapid  solution  of  the  latter,  but  has  no  effect  on 
the  former. 

The  Urobilinogen  Test  for  Hepatic  Function. — Neubauer  and 
others  have  shown  that  the  Ehrlich's  modified  diazo  reaction  (see 
page  102)  is  not  after  all  a  test  for  typhoid  fever,  but  often  oc- 
curs here  and  elsewhere  inasmuch  as  the  liver  when  involved 
sometimes  permits  urobilinogen  to  escape  unchanged  into  the 
urine;  and  it  is  this  substance  which  gives  the  test.  It  would 
thus  seem  that  we  have  found  a  very  valuable  as  well  as  ex- 
ceedingly simple  method  of  determining  whether  or  not  the 
"  liver  function  "  is  normal;  and  this  may  be  of  considerable 
diagnostic  profit.  Thus,  for  example  in  the  cirrhoses,  where  most 
of  the  cells  of  the  liver  are  simultaneously  involved,  this  organ 
may  be  unable  to  "wrork  up"  the  urobilinogen.  In  other  words, 
so  many  cells  are  injured  that  the  remainder  are  unable  (by 
virtue  of  their  inherent  possibilities  to  undergo  compensatory 
hypertrophy  or  other  change)  to  complete  the  work  expected  of 
that  organ.  The  test  appears  to  be  a  very  sensitive  one,  but 
never  occurs  in  perfect  health.  It  appears  to  be  of  great  value 
in  the  diagnosis  of  those  liver  ailments  where  the  greater  part  of 
the  organ  is  affected ;  viz.,  passive  congestion,  cirrhosis,  biliary 
obstruction,  severe  fevers  with  involvement  of  this  organ,  hepatic 
syphilis  and  angiocholitis.  Minor  hepatic  troubles  affecting 
most  of  the  cells  may  give  rise  to  urobilinogenuria  whereas  se- 
vere diseases  of  that  organ  affecting  only  a  small  portion  of  it 
may  cause  no  such  condition  because  enough  cells  are  left  un- 
injured to  assume  the  whole  work  laid  out  for  that  cell  com- 
munity. 

Do  not  heat  the  urine  or  the  reagent,  as  the  results  will  be 
confusing.  Two  drops  of  the  testing  solution  are  added  to  one 
dram  of  the  urine.  The  mixture  is  shaken  and  set  aside  at  room 
temperature.  If  urobilinogen  is  present,  a  beautiful  cherry-red 
color  will  develop  after  a  time  varying  from  a  minute  to  a  cou- 
ple of  hours.  A  yellowish  or  pinkish  tint  cannot  be  regarded  as 
positive.  The  testing  reagent  may  be  made  up  and  kept  indefi- 
nitely. It  is  prepared  by  dissolving  one  gram  of  paradimethyla- 


THE   URINE   IN   DISEASE.  115 

minobenzaldehyde  in  10  cc.  of  pure  hydrochloric  acid  and  then 
adding  five  drops  of  alcohol  and  enough  distilled  water  to  make 
up  50  cc.  total  quantity. 

Diazo  Reaction. — (See  Diazo  Versus  "VVidal,  page  101.) 

Significance  of  Urea  Content. — Normally,  about  500  grains  of 
urea  are  passed  daily,  but  this  output  varies  under  physiological 
conditions.  It  is  only  when  the  urea  runs  very  low  that  a  patho- 
logical significance  may  be  applied.  In  certain  forms  of  Bright 's 
disease,  and  in  pregnancy  where  eclampsia  is  feared,  its  estimation 
may  be  attempted  mainly  as  a  prognostic  procedure. 

Estimation  of  Urea. — Any  method  requiring  the  making  up  of 
fresh  quantitative  solutions  for  each  estimation  finds  small  favor 
with  the  practitioner.  The  Squibb  apparatus  requires  but  little 
of  this  work,  avoiding  at  the  same  time  the  use  of  the  irritating 
bromin.  This  apparatus  is  sold  by  instrument  dealers,  and  is  ac- 
companied by  full  directions  for  using. 

Significance  of  Uric  Acid. — In  small  amount,  uric  acid  is  nor- 
mal, but  in  increased  quantities — due  to  unknown  causes — it  may 
lead  to  the  formation  of  urinary  calculi,  to  gout,  and  to  other  forms 
of  arthritis. 

Detection  of  Uric  Acid. — In  a  cold  urine,  uric  acid  and  its 
homologues  appear  as  a  brick-red  precipitate.  A  little  heat  will 
cause  their  solution,  thus  differentiating  them  from  blood.1  A 
simple  test  for  one  of  the  compounds  accompanying  the  uric  acid 
proper  may  be  made  by  adding  1  or  2  drops  of  a  sugar  of  lead 
solution  to  the  sample,  when  a  flesh-colored  precipitate  will  be 
formed.  A  microscopical  examination  may  reveal  in  the  cold  urine 
characteristic  uric  acid  crystals. 

Estimation  of  Uric  Acid. — That  true  lithemia  occurs,  and  that 
an  increase  of  uric  acid  in  the  secretion  of  the  kidney  proves  its 
existence,  are  not  unquestioned  medical  truths.  This  statement 
does  not  refer  to  true  gout,  but  to  the  many  ailments  usually 
attributed  to  this  normal  urinary  salt,  and  for  these  reasons  the 
estimation  of  uric  acid  can  not  properly  be  considered  a  common 
procedure,  nor  has  it  earned  a  place  in  the  physician's  laboratory. 

Significance  of  Chlorides. — These  are  normally  present  in  the 
urine.  Continued  fever  or  serious  kidney  lesions  cause  decrease 
of  chlorides.  Cessation  of  excretion  of  chlorides  in  urine  forms 


1  Only    the    urates    are    dissolved,    and    such    quantity    of    the    acid    itself    as    may    be 
present  is  so  small  that  the  test  loses  none  of  its  value. 


116  LABORATORY    METHODS. 

the  basis  of  an  unfavorable  prognosis  in  pneumonia.     After  the 
crisis  is  successfully  passed,  the  chlorides  are  increased  in  amount. 
Estimation  of  Chlorides. — The  following  plan  is  simple,  and  at 
the  same  time  very  useful : 

1.  Remove,  if  necessary,  any  albumin  that  may  be  present. 

2.  Filter  if  necessary. 

3.  Take  2  ounces. 

4.  Add  1  drop  of  nitric  acid. 

5.  Add  3  drops  of  a  15-percent  solution  of  silver  nitrate. 

A  normal  amount  of  chlorides  produces  thick,  curdy  masses, 
whereas  greatly  diminished  chlorides  cause  only  a  slight  cloudiness. 
More  delicate  estimations  are  unnecessary  for  prognostic  purposes. 

Significance  and  Detection  of  Diacetic  Acid. — Diabetic  coma  is 
due  to  betaoxybutyric  acid,  but,  as  the  presence  of  this  is  detected 
with  difficulty,  search  is  usually  made  for  diacetic  acid,  a  body 
closely  related  and  usually  formed  simultaneously.  Diacetic  acid 
has  been  found  in  other  conditions,  and  is  of  little  diagnostic  im- 
port, but  its  appearance  late  in  sugar  diabetes  is  of  great  interest 
in  that  a  ccma  is  likely  to  follow,  and  hence  its  identification  be- 
comes of  great  prognostic  interest.  The  sample  must  be  fresh 
when  tested,  as  this  acid  is  very  volatile.  The  urine  must  be  added 
to  the  ferric  chlorid,  else  filtration  will  be  necessary  in  order  to  see 
the  color  reaction.  The  test  is  as  follows: 

1.  Into  a  test  tube  pour  about  2  drams  of  a  clear,  strong  solu- 
tion of  ferric  chlorid. 

2.  Add  1  or  2  drops  of  the  urine.     A  wine-red  color  indicates 
the  presence  of  diacetic  acid.     The  reagent  should  not  be  added  to 
the  urine,  as  is  generally  advised.     If  compounds  of  the  aromatic 
series  are  bcir.g  exhibited,  these  will  give  a  pseudotest.     In  such 
contingency,  recall  that  diacetic  acid  is  partially  decomposed  by 
boiling  the  urine  just  prior  to  the  test,  thus  reducing  the  intensity 
of  .the  reaction. 

Collecting  the  Sediment. — Whether  gravity  or  the  centrifuge  is 
employed  to  separate  the  sediment  from  the  liquid  is  immaterial, 
except  perhaps  that  the  first  method  requires  too  much  time.  The 
sediment  may  be  collected  from  beneath  the  supernatant  liquid  by 
the  following  method : 

1.  Use  a  long  pipette.  If  a  medicine  dropper  is  employed,  the 
technic  may  be  modified  to  apply  to  its  use.  It  is  sometimes  ad- 
visable to  select  this  sediment  from  the  bottom  of  a  bottle,  and 


THE  URINE  IN   DISEASE.  117 

therefore  a  small  glass  tube  drawn  to  a  point  should  be  a  part  of 
every  physician's  equipment.  With  the  index  finger  pressed 
against  the  top,  immerse  this  pipette  so  that  the  point  comes  in 
contact  with  the  sediment. 

2.  Now  carefully  relax  the  pressure  on  the  upper  end,  and  some 
of  the  sediment  will  be  drawn  into  the  tube.     Quickly  apply  the 
pressure  and  remove  the  pipette  from  the  sample.     In  case  the 
sediment  appears  to  be  in  strata,  specimens  from  the  several  layers 
may  be  taken. 

3.  On  a  piece  of  window  glass   (2x2  inches)   drop  at  different 
places  some  of  the  sediment,  and  examine  with  a  low-power  ob- 
jective and  narrowed  diaphragm.     In  case  there  is  any  question 
concerning  the  recognition  of  certain  elements,  drop  on  a  cover 
glass,  slightly  open  the  diaphragm,  r.nd  use  a  higher  magnification. 

Pus. — Separate  chemical  and  microscopical  considerations  of 
pyuria  are  almost  impossible.  When  its  origin  is  in  the  kidney 
tissue,  only  a  few  cells  are  usually  found,  and  the  companionship 
of  certain  other  elements — as  casts,  crystals,  and  epithelial  cells — 
may  aid  in  determining  the  source.  A  renal  pus  shows  a  tendency 
to  appear  and  disappear  at  intervals,  is  acid,  shows  no  tendency 
to  thread  formation,  and  its  cells  are  usually  well  preserved. 

In  cystitis,  if  acid,  differentiation  may  be  impossible,  but  if  alka- 
line, as  is  usually  the  case,  the  cells  tend  to  be  swollen  or  destroyed. 

In  urethritis  the  first  urine  voided  should  contain  much  pus, 
while  that  collected  in  a  second  glass  exhibits  but  little.  It  shows 
a  tendency  to  thread  formation — clap  threads.  . 

The  pus  cell  is  usually  a  pclymorphonuclear  leukocyte,  but 
lymphocytes  may  be  present.  There  should  be  little  difficulty  in 
ruling  out  epithelial  cells  and  unnucleated  red  corpuscles,  and  in 
case  of  doubt  the  nuclei  may  be  brought  out  by  adding  to  the  drop 
of  sediment  a  drop  of  1-percent  acetic  acid.  The  pus  of  pyelitis  is 
differentiated  with  difficulty.  When  desirable,  smears  and  stains 
may  be  made  for  the  tubercle  bacillus,  but  the  search  is  too  often 
very  discouraging. 

Casts — Etiology,  Types,  and  Differentiation. — A  complete  clas- 
sification of  these  elements  is  left  to  the  larger  books.  For  prac- 
tical purposes,  it  is  not  necessary  to  draw  fine  distinctions — any 
type  may  be  expected  in  the  several  kidney  lesions,  although  certain 
forms  may  be  more  typical  of  an  interstitial  inflammation  than  of 
a  parenchymatous  nephritis. 


118 


LABORATORY    METHODS. 


The  recognition  of  tube  casts  should  not  be  a  difficult  matter, 
but  nevertheless  much  confusion  exists  in  regard  to  this  point 
among  practitioners.  There  is  no  doubt,  however,  that  one  who 
has  once  really  seen  and  identified  these  elements  is  never  perplex*  <l 
in  the  future.  Some  of  the  more  common  sources  of  error  are  the 
following : 

1.  Mistakes  in  identity.     The  harmless  epithelial  cell  and   the 
extraneous  cotton  fiber  are  only  too  often  mistaken  for  casts. 

2.  Working   with    too    much   light.     Many    persons    neglect    to 
properly  narrow  the  diaphragm  in  making  examinations  of  the  un- 
stained preparations  of  urinary  sediment,  as  well  as  of  other  smears 
and  sections  which  have  not  been  treated  with  a  dye. 

3.  Attributing  to  the  flexible  and  mucus-like  cylindroids  unde- 
served individuality. 


\  B  C 

•Artifacts.      A,  granular  casts;  B,  vegetable  fibers;  C,  epithelial  cells  which  have 
lost  their  nuclei. 


Pig.  29. — 


The  cast  is  formed  in  the  uriniferons  tubule,  and  the  latter  may, 
in  fact,  be  considered  its  mold;  so  that,  if  there  is  blood  in  these 
tubules,  there  will  be  a  blood  car.t ;  if  there  is  pus,  a  purulent  cylin- 
der will  result,  etc.  The  granular  casts  represent,  in  all  probability, 
necrotic  epithelial  cells  which  line  the  uriniferous  tubules;  in  fact, 
certain  of  these  casts  contain  large  remnants  of  these  cells  or  the 
cells  themselves.  There  may  be  other  casts  representing  degenera- 
tive or  necrotic  changes,  as  certain  hyalin  or  fatty  casts.  AVhen 
large  numbers  of  bacteria  are  included,  a  so-called  bacterial  cast 
may  result. 

In  certain  pathological  conditions  individual  types  may  pre- 
dominate, although  any  or  all  of  the  others  may  be  present.  Thus, 
in  an  acute  nephritis,  search  is  naturally  made  for  the  epithelial, 
blood,  and  leukocyte  casts,  while  the  granular  and  hyalin  forms 


THE   URINE   IN    DISEASE. 


119 


are  more  characteristic  of  chronic  Bright 's  disease.  Epithelial 
casts  are  rarely  found  in  simple  interstitial  types  of  kidney  dis- 
ease. Bacterial  casts  indicate  a  very  grave  prognosis.  In  diabetes 
there  are  usually  expected  to  be  found,  at  some  stage,  short  hyalin 
casts. 

A  cast  should  not  be  confounded  with  a  cotton  or  flaxen  fiber, 
as  there  are  few  or  no  points  of  resemblance,  which  is  clearly  shown 
in  Fig.  29.  Often,  though  not  always,  these  fibers  lie  on  the  cover 
slip,  and  the  objective  must  be  lowered  before  any  of  the  urinary 
sediment  comes  into  view.  An  epithelial  cell  in  which  the  nucleus 
shows  but  faintly  or  not  at  all,  and  the  edges  of  which  tend  to 
"roll,"  seems  often  to  confuse  the  microscopist  initiate.  In  case 
of  doubt,  a  little  acetic  acid  or  a  drop  of  slightly  acidulated 


CD  E 

Fig.  30.- — Some  typical  epithelial  cells  from  the  urinary  passages.  A,  squamous  cell  of 
vagina  and  urethra;  B,  caudate  cells  from  pelvis  of  kklney,  ureter,  and  bladder;  C, 
cylindrical  cell  from  the  upper  portion  of  the  male  urethra;  D,  polynuclear  cell,  same 
origin  as  tailed  cell ;  E,  two  renal  cells. 

methyl  green  may  demonstrate  a  nucleus.  Do  not  forget  to  nar- 
row the  diaphragm,  which  admonition  is  emphasized  because  fail- 
ure to  do  this  is  one  of  the  chief  reasons  why  most  practitioners  fail 
to  see  casts.  A  real  cast  is,  however,  rarely  mistaken  for  an  epithe- 
lial cell  or  a  bit  of  extraneous  matter,  as  the  outlines  are  too  clearly 
cut  and  the  morphology  is  too  characteristic.  It  is  therefore  a 
fairly  safe  conclusion  that  where  doubt  exists  the  element  in  ques- 
tion does  not  properly  belong  to  the  pathologic  nomenclature. 
Casts  are  demonstrated  with  difficulty  in  a  urine  voided  several 
hours  before. 

Blood  Cells. — Blood  is  identified  microscopically  by  the  presence 
of  red  cells.  These,  unless  hemorrhage  is  recent,  are  rarely  intact, 
but  are  swollen,  and  usually  lack  some  of  their  pigment,  at  times 
even  forming  blood  shadows  (Fig.  30). l  Casts  signify  renal 


1  It  follows  that  in  some  urinary  specimens,  especially  those  where  the  examination 
has  been  delayed,  the  erythrocytes  can  not  be  identified  by  the  microscope  and  the 
presence  of  hemoglobin  must  be  demonstrated.  For  this  purpose  Meyer  has  devised 


120 


LABORATORY    METHODS. 


hemorrhages.  Here,  as  with  pus,  the  coexistence  of  certain  other 
elements  may  indicate  the  location  of  the  bleeding  point. 

Epithelial  Cells. — A  few  desquamated  epithelial  cells  may  be 
found  in  a  sample  of  normal  urine,  and  large  numbers  of  these 
elements  point  to  pathological  processes.  Unfortunately  the  shape 
of  the  cell  rarely  aids  in  diagnostics,  as  the  various  types  are  so 
widely  distributed.  Ordinarily  the  characteristic  cell  of  the  va- 
gina or  urethra  is  referred  to  as  a  flat  cell  (Fig.  3Q).  Vesicular 
denudations,  as  well  as  those  from  the  ureter  and  kidney  pelvis, 
usually  include  characteristic  star-shaped  and  "tailed"  cells. 
Very  small  round  cells,  with  spherical  nuclei,  are  most  likely  to  come 
from  the  uriniferous  tubules. 

Chemical  Sediments. — These  are  of  less  diagnostic  significance 
than  the  organic  elements.  The  following  is  a  brief  classification 
of  the  more  common  crystals : 


Fig.  31. — Comparison  of  the  more  usual  forms  of  the  common  crystals  met  in  urinary  sedi- 
ments. A,  uric  acid;  B,  ammonium  urate ;  C,  calcium  oxalate ;  D,  triple  phosphate; 
E,  calcium  carbonate. 

1.  Uric  Acid  and  Urates   (Brown  Color).     (Fig  31.)     Soluble 
only  in  warm  solutions.     Typical  uric  acid  crystals  are  of  a  rhom- 
boid shape,  and  those  of  ammonium  urate  have  an  appearance  not 
unlike  that  of  the  common  cockle-bur.     There  are  many  variations 
from  these  characteristic  forms,  but  certain  points  of  resemblance 
are  found  in  the  less  frequently  observed  types.     Occur  in  normal 
urine,  but  are  increased  in  gout. 

2.  Calcium  Oxalate.     Show  typical  envelope  shapes.     Soluble  in 
hydrochloric  acid  and  insoluble  in  acetic  acid.     Of  little  patho- 


an  excellent  test.  Prepare  the  reagent  by  heating  4  grams  of  pure  phenolphthalein,  20 
grams  of  potassium  hydrate,  about  15  grains  of  zinc  dust,  and  200  cc.  of  distilled 
water.  Prolong  the  heating  until  all  the  pink  color  disappears,  and  then  filter  and 
bottle.  Having  obtained  a  good  solution,  which  may  be  kept  a  Ions;  time,  the  test 
itself  is  simple.  Add  a  few  drops  of  this  reagent  and  a  drop  of  peroxid  to  a  few  cubic 
centimeters  of  the  urine.  A  pink  coloration  indicates  the  presence  of  hemoglobin. 
Make  a  control  test  with  a  normal  urine. 


THE   URINE   IN    DISEASE.  121 

logical  significance.  When  present  in  large  amounts,  these  crystals 
may  irritate  the  ureters  and  give  rise  to  symptoms  similar  to  those 
noted  in  renal  calculus.  Such  a  condition  has  been  termed  pain- 
ful oxaluria — oxaluria  dolorosa. 

3.  Triple  Phosphate.     Heat  causes  precipitation  rather  than  the 
solution  noted  with  urates.     The  coffin-lid  shape  is  typical.     Oc- 
curs in  ammoniacal  fermentation,  whether  in  a  diseased  bladder  or 
in  the  urinal. 

4.  Calcium    Carbonate.     Occurs    as   small   transparent    spheres, 
which  give  off  gas  (carbon  dioxid)  if  acid  is  added.     Occur  under 
the  same  conditions  as  the  triple  phosphate. 

Bacteria  in  General.— A  few  bacterial  cells  may  be  present  in  a 
normal  urine  freshly  voided  into  a  sterile  receptacle.  Urine,  on 
standing,  soon  becomes  contaminated  by  microorganisms  of  the 
air,  and  "spoiling"  occurs.  In  a  majority  of  cases  this  fermenta- 
tion is  alkaline  in  character  (ammoniacal),  and  such  a  urine 
abounds  in  germs  of  many  varieties. 

Parasites. — The  tubercle  bacillus  may,  with  difficulty,  be  identi- 
fied in  cases  of  tuberculosis  of  the  genital  tract.  See  Searching  for 
Germs  (page  48)  for  the  detection  of  the  gonococcus.  The  micro- 
organisms of  many  system  affections,  as  typhoid,  may  occur  in  the 
urine,  but  are  rarely  considered  from  a  diagnostic  standpoint.  The 
colon  bacillus  is  usually  blamed  for  an  acid  cystitis,  whereas  a 
bladder  affection  alkaline  in  character  is  often  due  to  the  bacillus 
proteus  vulgaris.  Multitudinous  varieties  of  bacteria  abound  in 
ammoniacal  fermentation  of  the  urinal.  Smegma  bacilli,  yeasts, 
molds,  amebae,  and  the  eggs  and  bodies  of  certain  animal  parasites 
have  been  identified,  but,  with  the  exception  of  the  first  of  these, 
are  very  rare.  It  follows,  therefore,  that  a  diagnosis  of  colon 
cystitis  on  the  appearance  of  rods  in  a  sample  urine  is  as  imprac- 
tical as  the  diagnosis  of  consumption  on  the  presence  of  a  cough. 
Strange  to  say,  many  of  these  impractical  procedures  are  often 
conducted  by  men  who  acknowledge  that  they  are  unable  to  identify 
a  urinary  cast  or  differentiate  between  albumin  and  urates. 

Extraneous  Matter. — The  various  vegetable  fibers  and  starches 
which  may  be  found  in  any  microscopical  preparation  have  been 
previously  considered  (page  30),  and  should  be  easily  recognized. 
They  are  introduced  accidentally  as  contaminations  from  the  hands, 
towel,  or  other  sources  not  easily  determined. 

Ammoniacal  Fermentation. — While  reference  has  been  made  to 


122  LABORATORY    METHODS. 

this  condition  (page  108),  a  few  special  points  may  be  emphasized. 
A  "spoiled"  urine  may  be  found  either  in  a  cystitis  or  in  a  stink- 
ing urinal.  In  the  former  case  it  is  most  likely  to  be  due  to  the 
bacillus  proteus  vulgaris,  but  when  voided  may  be  caused  by  many 
types  of  microorganisms.  Under  the  alkaline  cystitis  (page  122) 
the  findings  of  this  condition  have  been  listed,  and  they  differ  very 
little  from  those  here  noted  as  the  fermentation  in  the  urinal: 

1.  Pungent  odor,  due  not  only  to  ammonia  gas,  but  to  certain 
other  decomposition  products. 

2.  Marked  alkaline  reaction. 

3.  Presence  of  many  bacteria. 

4.  Dirty  white  or  gray  sediment,  which  shows  under  the  micro- 
scope the  coffin-lid  crystals  of  the  triple  phosphates  and  the  spher- 
ical carbonates. 

Urine  of  Specific  Urethritis. — Contains  clap  threads,  pus  cells 
containing  gonococci,  and  rarely  blood. 

Urine  of  Acid  Cystitis. — Acid  reaction.  Slight  fecal  odor.  Con- 
tains pus,  red  blood  cells,  and  epithelium.  Caused  commonly  by 
the  colon  bacillus. 

Urine  of  Alkaline  Cystitis. — Marked  alkaline  reaction.  Foul 
odor  of  ammonia  and  putrefactive  gases.  Contains  triple  phos- 
phates, pus,  epithelium,  and  rarely  blood.  Caused  commonly  by 
bacillus  proteus  vulgaris. 

Urine  of  Foudroyant  Cystitis. — Characterized  by  much  blood 
and  pus.  Caused  by  streptococci  and  other  virulent  germs. 

Urine  of  Pyelitis. — Rarely  shows  any  features  different  from 
those  of  acid  cystitis. 

Urine  of  Renal  Calculus. — Acid  reaction.  Contains  blood  and 
often  bits  of  urate  or  oxalate  gravels.1 

Urine  of  Vesical  Calculus. — This  presents  a  picture  of  a  severe 
cystitis,  with  blood  and  possibly  phosphatic  concretions. 

Urine  of  Renal  Hyperemia. — Small  amounts  of  albumin,  but 
few  or  no  casts,  with  little  or  no  blood.  In  the  passive  hyperemia 
of  mitral  insufficiency  the  urine  is  acid,  contains  many  urates,  and 
has  a  high  specific  gravity. 

Urine  of  Uremia. — Many  casts  of  all  types,  much  albumin,  and 
decreased  urea. 

Urine  of  Parenchymatous  Nephritis. — Small  amount  of  urine, 


1  The  presence  of  oxalate  crystals  in  the  urine  is  not  sufficient  proof  that  a  calculus 
is  lodged  in  the  renal  pelvis  or  ureter.  That  these  crystals  may  cause  distressing 
symptoms  resembling  those  of  renal  calculus  appears  to  be  unquestioned 


THE   URINE   IN   DISEASE.  123 

containing  much  blood  and  albumin,  and  of  a  high  specific  gravity. 
Contains,  besides  free  blood,  blood  casts  and  many  epithelial 
casts. 

Urine  of  Interstitial  Nephritis. — This  is  the  chronic  Bright 's 
disease.  It  is  characterized  by  much  urine,  containing  no  blood 
and  only  traces  of  albumin,  and  shows  a  low  specific  gravity.  Hya- 
lin  and  granular  casts  are  usually  present,  but  the  others  are 
rarely  found.  Cellular  elements  are  generally  few  in  number. 

Urine  of  Diabetes  Mellitus. — Much  urine,  usually  of  a  high 
specific  gravity.  Smells  sweet  and  has  but  little  color.  Glucose 
and  the  acetone  bodies  are  present.  Traces  of  albumin  and  the 
short  hyalin  casts  are  not  uncommon. 

Urine  of  Diabetes  Insipidus. — Much  urine  of  a  low  specific  grav- 
ity, but  shows  no  sugar,  acetone  bodies,  albumin,  etc. 

Urine  of  Autointoxication. — Variable  but  usually  small  amount 
of  urine  of  a  high  acidity,  sometimes  showing  traces  of  albumin 
and  hyalin  casts  but  invariably  contains  large  quantities  of  in- 
dican  or  indolacetic  acid.  Tests  for  these  as  well  as  a  bedside 
method  of  estimating  the  acidity,  may  be  found  in  the  appendix. 
Some  authorities  term  this  condition  acidemia  or  copremia. 

Acidosis  Versus  Acidemia. — Harrower  and  other  writers  have 
pointed  out  these  differences.  A  brief  classification  of  all  that 
pertains  to  the  acids  of  fhe  urine  is  here  given: 

1.  Normal  Acidity.     To  certain  phosphates  is  due  the  normal 
urinary  acidity. 

2.  Uric  Acid  Diathesis.     It  has  yet  to  be  proven  that  excess  of 
uric  acid  in  the  urine  increases  the  acidity  of  that  excretion. 

3.  Acidosis.     "When   the   urine   of   sugar   diabetes   contains   the 
acetone    bodies. 

4.  Acidemia.     A  condition  observed  in  autointoxication,  and  un- 
doubtedly caused  by  certain  acids  containing  sulphur,  by  indola- 
cetic acid,  and  by  other  products  formed  in  abnormal  intestinal 
putrefaction. 

Tuberculosis  of  the  Urinary  Tract. — The  tubercle  bacillus  is  not 
easily  found,  which  is  especially  the  case  if  much  blood  is  present, 
and  it  is  well  to  centrifuge  before  making  the  spreads.  The 
smegma  bacillus,  though  acid  fast,  shows  no  tendency  to  occur  in 
clumps.  If  any  doubt  exists,  it  may  be  advisable  to  wash  the 
stained  preparation  in  an  absolute  alcoholic  solution  of  1-percent 


124  LABORATORY   METHODS. 

hydrochloric  acid  for  ten  minutes,  which  will  decolorize  the  smegma 
bacillus,  but  the  tubercle  germs  will  remain  brightly  stained. 

lodin  Tests  in  Malingerers. — Under  certain  conditions  a  physi- 
cian may  desire  to  know  whether  his  patient  is  taking  the  medicine 
as  prescribed  or  dispensed.  By  adding  a  few  grains  of  potassium 
iodid  and  collecting  a  sample  of  the  urine,  that  drug  may  be 
easily  detected  as  follows:  To  the  urine  add  a  little  starch  solu- 
tion, and  then  add  1  or  2  drops  of  chlorin  water.  A  blue  color 
indicates  the  presence  of  the  iodid. 

Tampering  with  a  Urine. — The  authors  have  observed  several 
instances  of  this  kind.  A  quack  doctor  taught  his  patients  to  test 
for  albumin  and  sugar,  and  then  prescribed  at  intervals  the  oil  of 
copaiba.  One  woman,  insistent  that  she  had  diabetes,  was  finally 
informed  that  her  urine  contained  large  quantities  of  cane  sugar. 
The  addition  of  glucose  to  a  voided  urine  is  quite  common,  and 
Osier  records  one  case  where  it  was  introduced  into  the  bladder. 
Brick  dust  or  iron  rust  may  be  added  to  give  the  appearance  of 
urates  or  blood,  and  ammonia  may  be  added,  which  does  not,  how- 
ever, result  in  the  formation  of  the  typical  coffin-lid  crystals  of 
triple  phosphate,  but  in  certain  star-like  crystals.  A  candidate  for 
a  life  insurance  policy  may  bring  a  bottle  of  normal  urine  to  the 
office,  whereas  a  freshly  voided  sample  from  the  same  person  would 
show  sugar,  albumin,  or  casts.  The  physician  must  be  on  the  look- 
out for  deception. 

Less  Frequently  Applied  Procedures. — Some  tests  have  no  di- 
agnostic or  prognostic  worth,  and  others  of  great  value  are  rarely 
or  never  attempted  by  any  save  experts.  Both  of  these  classes  have 
been  combined  and  listed  as  follows: 

1.  Temperature  corrections  for  specific  gravity. 

2.  Detection  and  estimation  of  certain  salts  and  other  constitu- 
ents of  the  urine. 

3.  Several  tests  for  albumin  and  its  quantitative  estimation. 

4.  Certain  bacteriological  examinations,  etc. 

Value  and  Limitation  of  a  Practical  Urinalysis. — The  value  of 
the  tests  described  depends  on  their  proper  selection  and  applica- 
tion, and,  while  their  importance  is  too  often  underestimated,  the 
deductions  drawn  from  this  source  alone  are  of  little  value.  The 
urinalysis  is  only  another  link  in  that  chain  by  which  a  safe  diagno- 
sis is  determined. 


CHAPTER  XL 

MILK  AND  ITS  HOME  MODIFICATIONS. 
Apparatus. — 


1.  Hydrochloric  acid,  dilute. 

2.  Sulphuric  acid,  commercial,  slight- 

ly diluted. 

3.  Sulphuric  acid,  C.  P.,  concentrated. 

4.  Methyl  alcohol. 

5.  Fusel  oil. 

6.  Ammonia  water. 


7.  Centrifuge  and  special  tube. 

8.  Microscope   and   accessories. 

9.  Phenolphthalein,     1-percent     alco- 

holic solution. 

10.  Pipette  or  medicine  dropper. 

11.  Tincture  turmeric. 

12.  Urinometer. 


The  methods  given  here  are  those  which  are  used  successfully 
by  the  leading  pediatrists  of  the  country.  So  far  as  practical  pur- 
poses are  concerned,  the  formulas  for  the  home  modifications  are 
ideal  in  that  the  mixing  may  be  done  by  the  housewife.  These 
tests  and  estimations  are  exceedingly  simple,  but  the  lack  of  proper 
references  renders  it  necessary  to  include  in  this  chapter  more  de- 
tails than  might  be  desired.  Moffitt,  in  the  Journal  of  the  American 
Medical  Association,  has  ventured  to  criticise  the  absolute  accuracy 
of  the  formulas,  but  his  observations  are  at  variance  with  those  of 
the  authors,  who  have  noted  that  control  analyses  of  samples  after 
modification  seem  to  be  of  surprising  accuracy.  It  is  the  opinion 
of  many  authorities  that  it  is  unnecessary  for  these  to  be  abso- 
lutely accurate.  For  the  benefit  of  those  not  so  well  informed  on 
the  subject  the  authors  have  deemed  it  advisable  to  enter  into  detail. 

Substitutes  for  Mother's  Milk. — The  summer  months  is  the  time 
when  the  health  of  the  baby  is  generally  affected,  and  when  its 
food  must  be  changed  it  may  occur  to  the  physician  that  the  little 
patient  needs  modified  milk,  but  he  makes  no  effort  to  put  his 
opinion  into  practice.  The  home  modification  of  milk  and  the 
principles  of  infant  feeding  are  so  little  understood  by  the  profes- 
sion that  any  light  thrown  on  the  subject  must  be  of  more  than 
passing  interest.  Observations  in  a  number  of  cases  will  convince 


References. — Lowenburg:   Journal   of   American    Medical   Association,    vol.    LV,    No.   7, 
page  565;  Kerley:  Diseases  of  Children;  Koplick:  Pediatrics;  Holt:  Diseases  of  Infancy. 

125 


126  IiABORATORY   METHODS. 

the  physician  that  there  is  a  science  in  feeding  the  baby  which  is 
denied  the  maternal  milk. 

The  earliest  work  in  this  matter  was  done  by  T.  M.  Rotch  and 
G.  E.  Gordon.  The  work  of  the  Walker-Gordon  laboratories  is  to 
be  commended,  but  hardly  comes  within  the  scope  of  this  book,  as 
they  are  rarely  accessible  to  the  general  practitioner.  They  furnish 
the  milk  direct  on  prescription,  acting  in  the  same  capacity  as  the 
pharmacist,  and  merely  see  that  the  patient  gets  exactly  what  is 
ordered.  A  physician  who  is  ignorant  of  the  principles  of  infant 
feeding  can  place  no  blame  on  these  laboratories  for  poor  results. 
The  absence  of  these  facilities  should  not,  however,  render  helpless 
the  man  outside  of  the  larger  cities,  as  an  energetic  physician,  an 
intelligent  mother,  and  a  conscientious  milkman  can  accomplish 
just  as  good  results  as  the  best  equipped  metropolitan  laboratory. 

Maternal  nursing  is  most  to  be  desired.  The  woman  who  refuses 
to  nurse  her  child  deserves  censure,  but  the  physician  is  often  an 
unsuccessful  social  reformer.  Not  only  is  the  mother's  milk  more 
acceptable  to  the  infant,  but  nursing  the  child  aids  the  uterus  to 
contract  and  involute  properly,  and  especially  among  the  poor  and 
ignorant  should  maternal  nursing  be  encouraged.  Severe  post- 
partum  hemorrhage,  acute  infections,  tuberculosis,  and  certain 
chronic  nervous  diseases,  as  epilepsy,  are  contraindications.  Ma- 
ternal syphilis,  where  the  child  seems  to  be  healthy,  should  be  con- 
sidered a  contraindication,  although  the  healthy  parent  may  nurse 
with  safety  her  syphilitic  babe. 

The  best  substitute  for  the  milk  of  the  mother  is  that  of  some 
other  woman,  but  in  America  there  are  no  slaves  or  peasants,  and 
a  healthy  wet  nurse  is  either  a  luxury  or  an  impossibility.  Hid- 
den disease  is  always  a  menace  to  both  parties.  Mixed  feedings 
may  be  deemed  advisable  where  the  milk  of  the  mother  is  good,  but 
small  in  amount. 

Of  all  artificial  foods,  modified  milk  is  accepted  by  scientific 
men  as  ideal.  Its  real  merits  are  borne  out  by  clinical  experience, 
and  the  results  of  its. therapeutic  efficacy  may  be  seen  in  a  hospital 
ward  furnished  with  scientifically  prepared  modified  milk  from 
the  adjoining  milk  laboratory.  The  baby's  organs  of  nutrition, 
however,  form  a  machine  doubtless  more  complex  than  that  of  the 
adult,  and  no  physician  should  become  so  infatuated  with  this 
method  of  feeding  that  he  would  see  in  it  perfection,  as  there  is 
still  much  to  learn  about  feeding  the  baby.  Because  of  disappoint- 


MILK   AND   ITS   HOME   MODIFICATIONS.  127 

ments  to  those  who  were  at  first  too  optimistic  and  the  ignorance  of 
the  profession  as  to  the  simplicity  of  the  home  modification,  the 
various  proprietary  infant  food  concerns  exist.  The  products  of 
these  concerns  may  have  done  some  good,  but  unfavorable  results 
do  occur  from  their  use,  and  experience  shows  that  these  unfavor- 
able results  are  the  rule.  In  the  first  place,  they  are  stock  pre- 
scriptions, and  in  their  preparation  the  condition  of  the  patient 
is  not  and  can  not  be  taken  into  consideration.  Any  intelligent 
physician  will  regard  this  "panacea"  from  about  the  same  view- 
point that  he  would  look  on  any  other  cure-all.  A  beautiful  book- 
let may  give  directions  how  to  mix  it  with  cow's  milk,  but  only  the 
latter  is  needed,  as  it  is  cheaper,  safer,  and  better  for  all  babies, 
sick  or  well,  and  its  real  worth  is  showTn  by  the  attempts  to  imitate 
it.  These  statements  are  not  made  in  an  unfriendly  spirit,  but  cer- 
tain comparisons  are  presented  for  the  guidance  of  the  general 
practitioner. 

Proprietary  Foods  Versus  Modified  Milk. — There  have  been 
cases  in  which  the  proprietary  foods  have  been  prescribed  where 
they  either  fortunately  suited  the  condition  or  were  selected  by  a 
physician  who  understood  the  principles  of  feeding  and  knew  the 
composition  of  the  food,  and  who  applied  this  knowledge  to  the 
particular  infant.  Several  brands  may  have  been  cast  aside  as 
worthless  in  an  exhaustive  experiment,  and  one  found  to  fit  the 
case  just  in  time  to  avoid  fatal  results.  The  picture  of  the  healthy 
infant  is  shown  in  the  advertisements,  but  the  others  who  developed 
rickets,  vomited  up  their  food,  or  died  are  not  portrayed. 

The  following  are  the  advantages  and  disadvantages  of  the  pro- 
prietary foods,  as  well  as  those  of  cow's  milk  scientifically  modi- 
fied: 

Advantages  of  Proprietary  Foods. 

1.  Convenient  to  use. 

2.  Suit  some  babies  under  some  conditions. 

3.  Fairly  good  substitutes,   when  properly  modified,   for   cow's 
milk  when  the  latter  can  not  be  obtained  in  a  pure  state. 

Disadvantages  of  Proprietary  Foods. 

1.  Expensive,  and  usually  unnecessarily  so. 

2.  Not  ideal  substitutes  from  a  scientific  standpoint,  as  the  pro- 
teids,  fats,  and  carbohydrates  are  not  in  correct  proportion  even 
for  the  healthy  baby. 

3.  Not  ideal  substitutes  from  a  clinical  standpoint.     Unless  the 


128  LABORATORY    METHODS. 

food  happens  to  suit  the  case,  there  results  scorbutus,   rachitis, 
marasmus,  or  even  acute  inanition. 

4.  They  present  an  attempt  to  fit  the  patient  to  the  cure. 

5.  The  proteids  and  sugars  of  the  cereal  foods  are  entirely  dif- 
ferent from  those  of  the  animal  milks,  and,  although  their  amounts 
may  be  modified,  an  alteration  of  their  composition  is  impossible. 
Because  "proteids  are  proteids"  is  no  reason  why  bad  proteids 
should  be  substituted  for  good  proteids.     All  sugars  are  sweet,  but 
the  diabetic  may  safely  take  levulose  when  glucose  may  be  poison- 
ous to  him.     Sugar  of  milk  is  absent  in  many  of  these  foods. 

6.  Menace  infantile  life  because  they  are  offered  to  the  laity, 
and  the  helpless  mite  is  intrusted  to  the  untrained.     They  are  pre- 
scribed according  toxbottle  directions,  and  the  parents,  having  the 
physician's  recommendation,  are  under  the  impression  that  science 
can  do  no  more  than  they  in  saving  the  baby. 

7.  Menace  infantile  life  because  in  many  cases  the  manufacturers 
presume  on  the  ignorance  or  indifference  of  many  of  the  profes- 
sion, so  that  the  real  dangers  are  hidden. 

8.  Given  straight  or  modified,  no  artificial  food  contains  those 
milk  enzymes  known  to  be  so  necessary  to  the  infant,  unless  it  also 
contains  that  which  is  absolutely  necessary — the  fresh  milk  of  some 
mammal. 

Advantages  of  Modified  Cow's  Milk. 

1.  Approaches  nearest  to  mother's  milk,  and  may  be  further 
modified  to  suit  the  infant  when  even  mother's  milk,  if  obtainable, 
would  fail. 

Disadvantages  of  Modified  Cow's  Milk. 

1.  Widespread  belief  that  the  process  is  very  difficult. 

2.  Ignorance  of  the  profession  not  only  of  the  process  of  modi- 
fication, but  of  the  principles  of  infant  feeding. 

3.  Lack  of  laboratory  facilities. 

4.  Indifference  even  on  the  part  of  recent  graduates,  who  should 
know  how  to  feed  babies. 

Working  in  the  Dark. — Cow's  milk  is  crudely  modified  by  some 
physicians  by  decreasing  all  the  ingredients  simultaneously  by 
diluting  the  milk  in  toto;  then,  if  it  is  desired  to  bring  up  the  fat 
content,  cream  is  added,  or,  if  the  sugar  is  to  be  increased,  sac- 
charum  lactose  may  be  added.  It  is  seldom  necessary  to  increase 
the  proteids,  as  there  are  enough  or  too  much  in  cow's  milk.  At 
best  the  system  is  one  of  working  in  the  dark,  as  cow's  milk 


MILK   AND   ITS   HOME    MODIFICATIONS.  129 

varies  greatly.  The  reason  that  even  rickets  may  result  may  be 
seen  in  the  following  table,  in  which  the  proteids  of  the  cow's  milk, 
by  dilution  with  equal  parts  of  water,  have  been  brought  down  to 
coincide  with  those  of  woman's  milk,  but  there  is  a  great  variation 
in  the  fats. 

Proteids.  Fats.  Carbohydrates. 

Cow's   milk    3      percent.  4  percent.  5      percent. 

Cow's   milk   diluted..  1.5  percent.  2  percent.  2.5  percent. 

Woman's    milk    1       percent.  4  percent.  7      percent. 

There  must,  of  course,  be  a  good  milk  supply,  and  to  assure  this 
a  testing  of  milk  for  dilution,  cleanliness,  etc.,  appears  necessary, 
though  a  conscientious  milkman  may  materially  aid  the  physician 
in  this  matter.  The  family  of  the  young  patient  can  also  aid  in 
perfecting  a  suitable  modified  milk,  but  the  physician  should  thor- 
oughly understand  the  principles  of  infant  feeding. 

The  Laboratory. — This  is  a  secondary  matter,  but  important. 
Each  physician  may  have  his  own  work-room,  fitting  it  up  for  less 
than  he  pays  for  paregoric  and  infants'  anodynes;  or  several  physi- 
cians may  have  a  laboratory  in  common.  The  worker  needs  a  bot- 
tle of  sulphuric  acid  and  a  few  other  reagents,  and,  if  he  possesses 
a  centrifuge,  he  may  obtain  a  fat  testing  tube  at  small  expense. 
For  convenience  of  description,  we  shall  consider  the  laboratory 
work  and  the  prescribing  as  being  done  by  two  different  men.  The 
actual  mixing  of  the  baby's  milk  is  done  every  day  by  the  family 
according  to  directions  from  the  laboratory  man,  who  is  in  turn 
instructed  by  the  physician  in  charge  of  the  case. 

Writing  the  Prescription. — The  physician  may  be  his  own 
analyst,  but,  in  case  another  man  does  the  work,  his  relations  to  the 
latter  are  as  follows: 

1.  He  should  devise  a  prescription  to  suit  the  case,  and,  if  he  is 
not  sure  as  to  the  one  indicated,  should  study  up  the  subject. 

2.  He  should  see  that  a  sample  (one  quart)  of  the  milk  reaches 
the  analyst.     In  many  cases  the  milk  dealer  should  not  be  aware, 
for  baby's  sake,  that  this  examination  is  to  be  made. 

3.  The  prescription  should  state  the  amount  of  milk  required  for 
the  infant  every  twenty-four  hours. 

At  this  point  the  responsibility  of  the  prescriber  becomes  that  of 
the  laboratory  worker,  but  it  is  advisable  to  enlarge  on  these  three 
points  before  we  study  the  work  of  the  milk  laboratory. 


130  LABORATORY   METHODS. 

Let  us  first  consider  the  devising  and  writing  of  the  prescription. 
Many  of  the  poor  results  from  using  modified  milk  are  due  to  igno- 
rance in  this  matter.  A  physician  should  not  merely  write 

R  Modified  Milk   I  v 

Sig.,  etc. 

As  has  been  stated,  a  knowledge  of  the  principles  of  infant  feed- 
ing is  necessary,  and,  if  this  is  lacking,  it  may  be  obtained  in  a 
short  review  of  a  book  on  pediatrics.  The  authors  do  not  wish  to 
overstep  the  scope  of  this  volume,  but  emphasizing  a  few  principles 
will  not  be  out  of  place. 

Some  Principles  in  Baby  Feeding. — There  are  two  numbers 
which  every  physician  should  bear  in  mind — viz.,  453  and  471. 
Although  the  makeup  of  woman's  and  cow's  milks  vary,  for  prac- 
tical purposes  the  following  arrangement  will  answer: 

Fats.          Carbohydrates.      Proteids. 

Cow's  milk  4  5  3      (453) 

Woman's  milk    4  7  1      (471) 

First  let  us  consider  the  healthy  baby  where  maternal  milk  can 
not  be  obtained.  Many  of  the  bad  effects  of  unmodified  cow's  milk 
in  the  healthy  infant  is  due  to  the  high  proteicl  content  of  that 
secretion.  The  carbohydrates,  although  a  lesser  factor  in  these 
considerations,  should  also  be  changed  in  order  that  mother's  milk 
may  be  approximated  as  nearly  as  possible.  For  that  reason  a  471 
milk  may  be  tried,  but  experience  shows  that  when  beginning  a 
modified  feeding  it  is  often  best  to  reduce  also  the  fats,  and  a  popu- 
lar trial  mixture  has  resulted  in  the  261  combination.  If  the  lat- 
ter does  not  agree  with  the  baby,  it  may  be  modified,  and  symptom  ; 
should  be  the  guide  for  modifications.  Gastric  symptoms  indicate 
fat  indigestion,  and  this  substance  must  be  increased  or  lowered 
accordingly — generally  lowered.  When  intestinal  symptoms  pre- 
dominate— either  diarrhea  or  costiveness — the  proteids  are  at  fault. 
Early  symptoms  of  rickets  indicate  that  the  fats  must  be  increased 
at  once.  Such  symptoms  as  sweating  of  the  head,  restlessness  at 
night,  constipation,  beading  of  the  ribs,  and  craniotabes  are  im- 
portant, but  easily  overlooked.  Stool  analyses  rarely  hold  that 
value  observed  where  the  infant  is  sick,  and  the  apparently  patho- 
logical stools  which  may  be  passed  by  the  healthy  infant  are  sur- 
prising. 


MILK   AND   ITS   HOME    MODIFICATIONS.  131 

For  the  sick  baby  we  must  use  those  principles  indicated  in  the 
text  books,  and  we  must  not  forget  our  drugs — castor  oil  and 
peppermint  water.  Contrasted  with  the  healthy  infant,  the  ap- 
pearance of  the  stools  should  be  noted,  as  this  is  of  great  im- 
portance. (See  Every-Day  Stool  Tests,  page  154.)  An  entire 
change  of  the  prescription  or  its  abolition  may  be  necessary. 

When  the  baby  becomes  older,  or  even  with  the  sick  young  baby, 
it  may  be  advisable  to  add  certain  substances  found  neither  in 
the  milk  of  the  cow  nor  that  of  the  human,  but  which  clinical  ex- 
perience has  demonstrated  to  be  useful  should  certain  indications 
arise.  These  have  but  little  to  do  with  this  subject,  and  are  really 
not  foods,  but  tend  toward  drug  medication.  They  have  been  used 
in  the  city  laboratories  for  the  convenience  of  physicians,  and 
under  this  head  come  the  syrup  of  lime,  peptonization,  barley 
water,  whey,  and  buttermilk  feedings.  They  should  be  used  under 
the  direction  of  the  physician  in  charge,  but,  if  dispensed,  should 
not,  like  all  other  prescriptions,  be  refilled  without  his  sanction. 

Sample  for  Analysis. — This  investigation  is  usually  necessary 
for  many  reasons.  In  the  first  place,  all  milks  differ  in  fat  con- 
tent. The  variations  in  the  other  constituents  are  less  marked, 
and  usually  need  not  be  considered.  The  amount  of  fat  in  a  given 
milk  varies  according  to  the  breed  of  the  cows,  the  time  of  the  year, 
grazing  conditions,  first  milk  or  top  milk,  whether  the  milk  comes 
from  a  single  cow  or  a  herd,  etc.  Even  if  the  composition  of  all 
milks  were  constant,  the  ignorance  of  many  dealers  renders  it  ad- 
visable to  always  be  assured  of  their  purity.  Dr.  Woods  Hutchin- 
son  says  that  one  teaspoonful  of  milk  may  contain  more  inhabitants 
than  the  city  of  New  York.  If  these  were  all  lactic  acid  bacilli, 
no  harm  would  result,  but  there  is  no  natural  selection.  Dr. 
Hutchinson  states  that  90  percent  of  the  injurious  effects  of  milk 
is  due  to  the  germs  of  plain,  common  dirt,  and  this  comes  not  only 
from  the  barnyard,  but  from  unwashed  milk  cans  and  other  avoid- 
able sources.  Asepsis  is  no  less  important  here  than  elsewhere, 
and  sterilization,  except  for  long  journeys,  is  rarely  necessary  and 
even  harmful  in  many  cases. 

Tampering  with  Baby's  Food. — We  are  too  often  shocked  to 
learn  that  the  apparently  honest  milkman  is  disposed  to  tamper 
with  his  milk,  and  evidently  infanticide  is  justifiable  in  his  eyes. 
He  will  add  water  to  increase  his  profits,  but,  worse,  he  will  add 
some  poison  to  inhibit  the  lactic  acid  bacillus,  unmindful  of  the 


132  LABORATORY    METHODS. 

other  varieties  which  nevertheless  proceed  to  multiply.  He  re- 
moves the  danger  sign — the  milk  does  not  "sour,"  and  it  is  impos- 
sible to  determine  whether  it  is  fresh  or  spoiled.  The  milkman  is 
saved  the  expense  and  trouble  of  ice,  but  the  consumer  is  subject 
to  his  poisons.  Analysis  of  the  milk  guards  against  these  dangers, 
but  it  is  advisable  to  select  a  milk  with  an  apparently  good  cream 
content  and  one  apparently  clean. 

Sterilization  is  never  advisable,  and  pasteurization  is  permissible 
only  under  unusual  conditions.  Some  of  the  germs  may  be  killed, 
but  their  poisons  prevail.  The  sugar  is  changed  to  caramel,  the 
taste  of  the  milk  is  altered,  there  may  be  some  coagulation  of  the 
proteids,  the  enzymes  are  destroyed  or  altered,  and  constipation 
usually  results.  Scurvy  is  caused  no  less  by  sterilized  milk  than 
by  the  proprietary  foods.  Fresh  milk,  ice,  and  cleanliness  are 
points  which  need  emphasis.  Mechanical  filtration  through  cotton 
is  never  a  safe  procedure.  It  is  best,  when  possible,  to  arrange 
with  some  honest  dealer  for  the  milk  of  some  certain  cow  or  herd, 
and  to  insist  on  cleanliness,  being  specific  as  to  directions  and,  if 
necessary,  paying  more  for  this  milk;  but  even  then  certain  analy- 
ses may  be  considered  advisable. 

Amount  Used  Daily. — The  laboratory  man  must  know  the 
probable  amount  of  milk  necessary  for  the  day's  feeding,  which  is 
usually  determined  with  ease.  In  case  the  babe  has  never  taken 
artificial  food,  an  estimate  may  be  made  and  the  formulas  subse- 
quently modified  according  as  to  whether  the  amount  is  too  large 
or  not  sufficient.  The  amount  will  vary  with  the  age  of  the  child, 
the  number  of  feedings  daily,  state  of  health,  etc. 

Duties  of  the  Physician. — If  the  physician  does  not  do  the  actual 
work,  he  will  write  the  prescription  to  suit  the  case,  and  see  tluit 
a  sample  of  the  milk  reaches  the  laboratory. 

Duties  of  the  Analyst. — Each  physician,  as  has  been  stated,  nuiy 
do  his  own  work,  or  at  least  one  physician  in  each  community 
should  be  prepared  to  make  the  tests  and  estimations.  The  ex- 
pense of  equipment  is  small,  and  the  technic  as  described  in  this 
work  is  exceedingly  simple. 

1.  General  appearance  of  the  milk  as  to  color,  odor,  amount  of 
cream,  etc. 

2.  Specific  gravity. 

3.  Reaction. 


MILK   AND   ITS   HOME    MODIFICATIONS.  133 

4.  Microscopy. 

5.  Tests  for  chemical  purity.     (When  searching  for  germs,  refer- 
ence may  be  made  to  Searching  for  Germs,  page  37.) 

6.  Quantitative  estimation  of  fat  content. 

7.  Modification,  which  consists  of  devising  the  amounts  of  cream, 
milk,  water,  and  milk  sugar  to  be  used,  bearing  in  mind  the  follow- 
ing factors: 

(a)  Composition  of  the  sample  as  determined  by  the  tests. 

(b)  The  physician's  prescription. 

(c)  Amount  to  be  made  up  daily. 

(d)  Certain   stock   formulas  which   experience  has  shown   will 
give  mixtures  that,  when  subjected  to  analysis,  show  the  desired 
composition. 

A  study  of  the  forms  below,  being  similar  to  those  used  in  hos- 
pitals, will  give  an  idea  concerning  the  meaning  of  the  above  ar- 
rangement. The  first  is  a  prescription  written  for  a  healthy  baby 
which  is  denied  the  maternal  milk,  followed  by  the  report  of 
directions,  etc. 

R     Fats    2  percent. 

Carbohydrates    6  percent. 

Proteids     1  percent. 

Amount   daily    20  fluidounces. 

Report.     Milk    normal,    the    cream    containing    16    percent    fat. 
Modification.     As  follows: 

Cream    1%  fluidounces. 

Lactose    1  ounce. 

Milk    3y3  fluidounces. 

Water    15  fluidounces. 

The  above  milk  is  mixed  by  the  family.  It  is  made  up  from 
cream,  milk,  and  water  to  the  20  fluidounces  and  then  the  sugar  is 
added.  It  will  be  remembered  that  when  a  solid  dissolves  in  a 
liquid,  the  bulk  is  not  perceptibly  increased. 

Analysis  of  Cow's  Milk. — Color.  This  should  vary  from  a  white 
to  a  bluish  tint,  according  to  the  amount  of  cream.  Certain  ab- 
normal colors  may  be  due  to  bacteria.  The  color  of  the  collustrum 
is  yellow,  and  needs  no  comment.  The  following  arrangement  will 
aid  in  the  classification  of  such  milks : 


134  LABORATORY    METHODS. 

Color.  Etiological  agent. 

Blue     Bacillus  cyanogenus. 

Violet .Bacillus  violaceus. 

Pink    Bacillus  prodigiosus. 

Red    Bacillus  lactis  erythrogenes. 

Yellow     Bacillus  synxanthus. 

Gelatinous  color  and  consistency Bacillus  lactis  viscosus. 

Blood  may  color  milk  from  a  bright-red  to  a  dark-brown. 

Odor.  Abnormal  odors  are  rarely  due  to  added  preservatives, 
as  these  occur  in  very  small  amounts.  The  gelatinous  milks  may 
possess  a  very  offensive  odor,  and,  strange  to  say,  the  most  dis- 
gusting of  these  cause  no  symptoms  when  ingested,  whereas  an 
apparently  perfect  milk  may  teem  with  death-dealing  microorgan- 
isms or  contain  formaldehyd  or  borax  in  very  small  quantity.  Cer- 
tain vegetables,  as  turnips,  cause  a  distinct  and  characteristic  odor. 
A  bitter  milk  may  be  explained  by  the  presence  of  certain  bacteria, 
purposely  added  poisons,  etc.  Milk  absorbs  odors,  especially  when 
stored  in  ice  chests  with  melons,  cucumbers,  canned  salmon,  etc. 

Amount  of  Cream.  In  a  regular  pint  bottle  which  has  stood  over 
night  the  upper  cream  layer  should  by  linear  measure  make  up 
about  one-third  of  the  entire  amount. 

Specific  Gravity.  This  may  be  taken  with  an  ordinary  urinome- 
ter  and  should  average  1.030.  In  case  it  is  much  more,  there  is 
sufficient  reason  to  suspect  that  cream  has  been  removed.  If  it  is 
considerably  less,  the  milk  has  in  all  probability  been  watered. 

Reaction.  Milk  is  acid  when  tested  with  phenolphthalein  solu- 
tion. It  is  practically  never  alkaline  unless  putrefactive  changes 
are  present  or  chemicals  have  been  added.  Acidity  is  increased  as 
the  milk  sours. 

Microscopy.1  If  the  cow  is  healthy,  only  a  few  leukocytes  and 
epithelial  cells  may  be  present  in  her  milk.  Leukocytes  in  con- 
siderable number  point  to  infection. 

Detection  of  Formaldehyd.  To  4  drams  of  milk  in  a  test  tube 
add  1  dram  of  commercial  sulphuric  acid.  Do  not  mix,  but  permit 
the  acid  to  form  a  layer  below  the  milk.  A  violet  ring  at  their 
junction  is  proof  that  formaldehyd  is  present.  This  test  is  ex- 
ceedingly simple  and  delicate,  and  but  two  precautions  are  neces- 
sary : 


1  Experts  are  able  to  obtain  merely  from  a  microscopical  examination  considerable 
information  as  to  the  probable  percentage  of  fat.  A  granular  tendency  of  the  droplets, 
or  when  these  are  much  too  large,  points  to  a  paucity  of  fat. 


MILK   AND   ITS   HOME    MODIFICATIONS. 


135 


5CC 


1.  The  reaction  depends  on  the  presence  of  iron  contained  in  the 
commercial  sulphuric  acid;  hence,  if  pure  sulphuric  acid  is  used, 
two  drops  of  ferric  chlorid  should  be  added  to  it. 

2.  A  pseudo-reaction  may  occur  if  acid  is  concentrated,  or  the 
charring  of  the  milk  may  obscure  the  true  reaction ;  hence  an  acid 
of  about  1.700  specific  gravity — i.  e.,  slightly  diluted — should  be 
employed. 

Detection  of  Borax  and  Boric  Acid.  Mix 
in  an  evaporating  dish  1  dram  of  the  milk  with 
1  dram  of  the  fresh  tincture  of  turmeric  and 
heat,  evaporating  slowly  to  dryness.  Add  2 
or  three  drops  of  hydrochloric  acid  (dilute) 
to  the  residue  and  evaporate  to  dryness  once 
more.  Pink  or  red  colorations  are  positive  in- 
dications, and  a  drop  of  ammonia  water  should 
change  either  to  a  green.  This  test  takes  some 
time,  and  is  rarely  necessary  as  a  routine  pro- 
cedure. A  milk  which  shows  no  formaldehyd 
and  which  refuses  to  sour  is  likely  to  contain 
borax  or  boric  acid.  The  chief  source  of  er- 
ror is  too  rapid  evaporation  by  heat  from  the 
free  flame.  A  good  substitute  for  the  water 
bath  is  to  place  the  evaporating  dish  on  the  flat 
lid  of  a  kettle  of  hot  water. 

Detection  of  Sodium  Bicarbonate.  Its  prob- 
able presence  may  be  determined  by  adding  a 
drop  of  any  inorganic  acid — for  example, 
nitric  acid.  In  case  soda  is  present,  gas  will 
he  given  off  and  the  surface  of  the  milk  will 
froth.  In  case  other  alkalies  are  added,  a 
drop  of  any  chemical  indicator  will  show  at 
once  the  nature  of  the  deception.  The  value 
cf  these  tests  would  be  limited  in  a  decom- 
posed milk. 

AYhile  it  is  true  that  tests  for  chemical  preservatives  need  not 
be  made  in  all  cases,  yet  positive  reactions  are  often  found  where 
they  might  be  least  expected.  Such  poisons  as  have  been  men- 
tioned are  not  usually  added  to  milk  during  the  colder  months. 

Quantitative  Estimation  of  Fat.  This  is  necessary  with  all 
creams,  except  perhaps  those  in  which  previous  test  has  shown  a 


Fig.  32 — Tube  for  fat 
estimations  which 
.may  be  used  with  an 
ordinary  centrifuge. 


136  LABORATORY    METHODS. 

definite  percentage  of  fats.  For  a  few  cents  a  special  tube  (Fig. 
32)  may  be  purchased  which  may  be  used  with  the  ordinary  centri- 
fuge. A  mixture  of  1  part  of  cream  and  4  parts  of  water  is  added 
with  a  pipette  to  the  5  cc.  mark.  Add  1  drop  of  the  Leffman-Beam 
solution,  made  up  as  follows: 

R    Hydrochloric    acid    ............................   50  drops. 

Methyl    alcohol    ...............................    13  drops. 

Fusel    oil    ....................................    37  drops. 

Mix  by  shaking,  and  then  ad'd  concentrated  C.  P.  sulphuric  acid 
drop  by  drop,  shaking  constantly  or  rotating  tube  until  the  zero 
mark  is  reached.  Centrifugalize  five  minutes  and  then  read  per- 
centage of  fats  directly  from  scale.  Multiply  by  five,  which  gives 
the  percentage  of  fats  in  the  sample  of  cream. 

Formulas.  —  These  are  stock  formulas,  and  their  use  has  been 
previously  considered  (page  133).  The  following  letter  symbols 
and  formulas  are  recommended  for  the  home  modification  of  milk  : 

Q  —  Quantity  desired  for  twenty-four  hours'  feeding. 

F  —  Desired  fat  percentage  in  modified  milk. 

S  —  Desired  sugar  percentage  in  modified  milk. 

P  —  Desired  proteid  percentage  in  modified  milk. 

FF  —  Percentage  of  fat  found  in  the  cream  by  analysis. 

C  —  Amount  of  cream  to  be  used  in  the  prescription. 

M  —  Amount  of  milk  to  be  used  in  the  prescription. 

"W  —  Amount  of  water  to  be  used  in  the  prescription. 

SS  —  Amount  of  milk  sugar  to  be  used  in  the  prescription. 

Formulas  for  Milk  Modifications.— 


SS= 


4 

(S-F)XQ 


100 
W  =  Q—  (M  +  C) 

Example.     Taking  the  above  formula  as  a  basis,  substitute  for 
it  a  20-ounce  mixture  that  is  to  contain  2  percent  fats,  6  percent 


MILK   AND   ITS   HOME   MODIFICATIONS.  137 

carbohydrates,  and  1  percent  proteids,  and  where  the  cream  has 
shown  16  percent  fat. 

20 

C  — X  (2  —  !)  =  1%  fluidounces. 

16  —  4 

20  X  1 
M  =  — 1%  —  3y3  fluidounces. 

(6  —  1)  X2<> 

SS  = =  1  ounce. 

100 

W  =  20  —  (31/3  -(-  1%)  =  15  fluidounces. 

It  will  be  noted  that  "Q"  is  made  up  by  the  addition  of  the 
computed  quantities  of  cream,  milk,  and  water  respectively.  The 
milk  sugar  dissolves  without  increasing  the  bulk  to  any  extent. 

Less  Frequently  Applied  Procedures. — These  include  mainly 
the  bacteriological  tests.  Dr.  Hutchinson's  Manhattan  in  a  spoon 
consists  of  as  many  nationalities  as  does  the  real  Ghetto,  from 
which  it  may  be  seen  how  impossible  it  would  be  for  the  general 
practitioner  to  isolate  and  study  this  population. 

Analysis  of  Maternal  Milk. — A  search  for  a  pathological  leuko- 
cytosis  or  an  estimation  of  fat  may  be  seldom  attempted  by  the 
practitioner,  but,  with  these  possible  exceptions,  little  practical 
information  is  to  be  gained  from  a  study  of  this  secretion.  It 
should  be  understood  that  some  of  the  germs  of  an  acute  infection 
may  pass  into  the  milk,  and  that  a  laboratory  examination  will  not 
be  necessary  to  condemn  it. 

The  questions  of  how  to  overcome  the  difficulties  that  may  be 
met  and  the  value  and  limitations  of  certain  procedures  have  been 
previously  considered  in  descriptions  of  the  technic. 


CHAPTEE  XII. 

SOME  SIMPLE  WATER  ANALYSES. 

Apparatus. — This  is  listed  preceding  each  test,  and  necessarily 
depends  on  the  selection  of  the  tests  made  by  the  analyst. 

These  tests,  when  compared  with  those  procedures  usually  de- 
scribed, are  simple.  The  recommendations  made  to  the  gene  fa  1 
practitioner  may  be  criticised,  but  a  careful  study  of  the  matter 
will  show  that  the  analysis  by  the  chemist  at  a  distance  is  not  in 
every  case  perfectly  satisfactory.  In  order  to  avoid  any  unfair 
interpretation  of  the  value  of  these  investigations,  the  authors  ask 
that  a  careful  study  be  made  of  this  chapter.  In  all  tests,  only 
the  water  used  for  drinking  purposes  is  considered. 

Scientific  Versus  Practical  Analyses. — A  practical  examination 
of  drinking  water  is  in  all  cases  useful  and  in  some  instances  in- 
dispensable. A  full  and  scientific  investigation  will  reveal  certain 
facts  that  are  as  yet  of  little  or  no  real  value,  and  do  not  receive 
consideration  in  this  book.  It  follows,  therefore,  that  any  criti- 
cism of  the  methods  that  are  recommended  can  not  properly  be 
offered  by  individuals  interested  commercially  in  the  "perfected 
water  laboratory."  It  is  not  the  intention  to  recommend,  without 
limitation,  every  investigation  mentioned  in  this  book,  for  in  this 
matter,  as  in  other  lines  of  work,  a  certain  amount  of  practice 
is  necessary.  It  may  be  advisable,  in  turning  over  the  practical 
examination  of  drinking  waters  to  the  physician,  to  state  two 
propositions  and  then  to  attempt  their  proof: 

1.  The  physician  may  be  able,  after  a  little  practice,  to  condemn 
a  drinking  water  quite  as  quickly  as  an  expert. 

2.  No  chemist  or  bacteriologist  can,  from  the  examination  of  a 
water  sample,  recommend  it  for  drinking  purposes,  and  this  ap- 
plies to  the  expert  as  well  as  to  the  practitioner.     That  a  water  is 
probably  safe  can  not  be  determined  any  quicker  by  the  extended 
scientific  examination  than  by  carrying  out  the  work  as  here  indi- 


Referehces. — Jordon :  General  Bacteriology;  Prcscott  and  Wilson:  Elements  of  Water 
Bacteriology:  Harrington:  Practical  Hygiene.  Very  few  books  issued  prior  to  the 
past  two  years  bring  this  subject  down  to  date. 

138 


SOME   SIMPLE   WATER   ANALYSES.  139 

cated.  It  should  be  remembered,  however,  that  in  this  chapter  is 
considered  only  a  suspected  water,  and  not  the  larger  sanitary 
questions — not,  fcr  example,  the  typhoid  epidemics,  where  milk  or 
flies  may  be  the  carriers,  and  where  expert  assistance  is  always  de- 
manded. 

The  first  proposition  may  be  proven  by  the  actual  selection  and 
description  of  the  tests,  their  limitations,  etc.,  together  with  a  thor- 
ough study  of  these  points  by  the  physician  and  actual  practice 
with  samples. 

The  second  proposition  may  seem  more  startling,  and  demands 
discussion  at  once.  Unfortunately,  for  analytical  purposes,  the 
nature  of  the  bacterial  contamination  of  water  is  of  much  more 
importance  than  its  actual  amount.  A  water  which  yesterday  con- 
tained the  germs  of  typhoid  may  show  none  today,  and  these  same 
germs  may  be  found  tomorrow  or  even  immediately  after  the 
samples  were  taken.  The  water  may  be  sparkling,  clear,  and  with- 
out odor,  and  a  careful  chemical  examination  may  reveal  the 
minimum  amounts  of  salts  resulting  from  organic  decomposition. 
A  thorough  bacteriological  examination  may  neither  show  evi- 
dences of  sewage  contamination  nor  may  it  identify  specific  patho- 
genic microorganisms.  The  fact,  therefore,  remains  that  no 
laboratory  analysis  can  at  present  recommend  for  drinking  pur- 
poses any  certain  water. 

Analysis  of  Commercial  Waters. — Purgative  waters — those  rec- 
ommended for  "kidney  disease,"  "rheumatism  of  the  young  man," 
"health  waters,"  etc. — are  not  considered  in  these  tests.  They 
contain  large  amounts  of  mineral  water  derived  from  deep-seated 
natural  deposits,  and  in  most  of  them  the  saline  purgatives  abound. 

Detection  of  Poisonous  Chemicals. — These  are  rarely  found  in 
drinking  waters.  Seme  western  rivers  have  been  said  to  contain 
in  solution  small  amounts  of  arsenic  and  antimony  (Vaughan). 
River  water  may  be  contaminated  by  certain  discharges  from  fac- 
tories— as,  for  example,  a  river  near  a  chemical  manufactory  may 
be  so  poisonous  that  all  fish  in  its  water  may  die.  Chemical  poi- 
sons may  be  purposely  thrown  into  a  well  or  a  stream,  and  in  this 
manner  families  or  even  portions  of  armies  have  been  affected. 
The  method  of  detecting  these  poisons  will  be  found  in  Detection 
of  the  Common  Poisons,  page  85. 

Changing  Water. — Various  gastrointestinal  disturbances  may 
result  from  drinking  a  "new"  water,  caused,  when  that  water  is 


140  LABORATORY    METHODS. 

pure,  by  mineral  salts  occurring  in  amount  different  from  that  to 
which  the  alimentary  tract  is  accustomed. 

Goiter  Waters. — The  authors  have  had  opportunity  to  investi- 
gate so-called  goiter  waters  in  two  different  localities,  and  are  con- 
vinced that  the  mineral  theories  are  not  well  founded.  One  of 
these  villages  obtained  its  water  almost  directly  from  the  Missis- 
sippi river.  No  specific  amebae  were  found  in  any  of  the  many 
samples  examined.  The  goiters  occurred  only  in  women  who  had 
spent  most  of  their  lives  in  the  town,  and  in  several  of  these  cases 
were  found  typical  symptoms  of  Basedow's  disease.  In  no  instance 
was  the  condition  apparent  before  the  age  of  12  to  14  years,  but 
this  "goiter  of  puberty"  usually  remained  throughout  life.  All 
women  born  in  the  village  were  not  affected,  but  one  who  had  come 
to  the  place  when  45  years  of  age  developed  symptoms  at  70. 

Odor  of  Waters. — The  once  popular  notion  that  the  water  with 
no  odor  was  safe  for  drinking  purposes  has  'given  place,  seemingly, 
to  the  idea  that  a  foul  smell  is  necessary  for  a  safe  and  "healthy" 
water.  A  bad  odor  may  indicate  sewage  contamination  or  the 
presence  of  dead  toads,  rats,  moles,  etc.,  but  beyond  this  has 
little  to  do  with  the  purity  of  the  water.  Other  causes  of  odors 
are: 

1.  Pig-pen  and  grassy  odors  are  due  usually  to  green  algae  of 
shallow  warm  waters. 

2.  Geranium,  oily,  and  fishy  odors  are  due  to  certain  other  algae. 

3.  Musty  odors  are  observed  sometimes  in  sewage  contamination, 
but  are  due  usually  to  certain  molds. 

4.  A  hydrogen  sulphid  odor  is  due  usually  to  the  action  of  cer- 
tain bacteria  on  the  sulphates. 

5.  Putrefactive  odors  are  due  not  only  to  dead  animals,  but  to 
decaying  vegetable  matter  in  stagnant  pools  or  wells.     (See  page 
141.) 

Reaction  of  Water. — This  is  usually  so  variable  as  to  be  of  little 
practical  import. 

Detection  of  Lead. — Symptoms  of  plumbism  may  direct  suspi- 
cion to  the  water  supply.  If  lead  pipes  are  used  and  several  peo- 
ple become  ill,  incrimination  of  the  water  is  almost  inevitable.  To 
8  ounces  of  the  sample  add  l1/^  grains  of  potassium  bichromate. 
A  turbidity  should  result,  which  in  twelve  hours  will  show  as  a 
slight  precipitate  on  the  bottom  of  the  glass  vessel.  It  is  best, 
when  making  this  test,  to  set  the  vessel  on  an  intensely  black  back- 


SOME   SIMPLE   WATER   ANALYSES.  141 

ground  and  observe  it  at  different  angles.  Control  tests  with-  dis- 
tilled water  and  those  containing  traces  of  lead  should  be  made. 

Animal  Parasites  in  Water. — Pinworms  and  roundworms  are 
often  distributed  by  water.  The  bothriocephalus  latus  is  spread 
by  the  fish  of  the  Baltic,  and  has  been  seen  in  several  American 
clinics.1  Other  forms  of  tapeworm,  trichina,  and  the  several  va- 
rieties of  the  vermes  are  not  usually  spread  by  drinking  water,  but 
many  of  the  tropical  worms  are  spread  in  this  manner. 

Dead  Animals  in  Water. — The  diagnosis  of  this  condition  is  not 
usually  difficult,  and  the  physician  is  rarely  consulted.  A  drain- 
ing of  the  reservoir  may,  however,  show  no  traces  of  dead  animals, 
but  the  odor  may  nevertheless  persist.  Such  a  water  supply  need 
not  for  that  reason  be  condemned,  as  putrefactive  odors  arise  from 
the  anaerobic  decomposition  of  vegetable  matter,  which  points  at 
once  to  stagnation.  Connecting  the  pump  nearer  the  bottom  of  the 
well  or  filling  up  the  stagnant  space  with  sand  will  usually  solve 
the  problem.  (Harrington.)' 

Algae  in  Water. — Vegetable  life  under  water  performs  the  same 
functions  as  do  the  higher  forms  on  land,  working  over  animal 
excreta  into  assimilable  matter.  If  possible,  the  various  algae 
should  not  be  disturbed,  as  it  is  an  established  fact  that  they  will 
destroy  sewage  bacteria.  Some  algae  give  off  obnoxious  odors,  and 
may  cause  various  gastrointestinal  symptoms.  The  cause  is  not 
usually  difficult  to  find,  and  has  been  mentioned  in  the  preceding 
paragraph.  Such  algae  should  not  be  destroyed  by  copper  solu- 
tions, as  is  usually  recommended,  but  proper  measures  should  be 
adopted  to  avoid  stagnation.  When  these  small  water  plants  re- 
ceive plenty  of  oxygen,  their  presence  is  more  desirable  than  their 
absence. 

Isolation  of  the  Typhoid  Bacillus. — From  what  has  been  said  it 
seems  unwise-  for  the  practitioner  to  attempt  any  procedure  so  dif- 
ficult and  so  discouraging  as  the  isolation  of  specific  pathogenic 
bacteria.  The  typhoid  bacillus  has  been  identified  in  suspected 
drinking  waters  by  Kiibler,  Neufeld,  Fischer,  Flatau,  and  others. 
In  the  light  of  our  present  knowledge  an  examination  for  its  source 
is  hardly  justifiable,  save  by  the  expert  as  a  part  of  a  complete 


1  Dr.  A.  S.  Warthin  has  found  the  bothriocephalus  measle  in  Lake  Superior  burbot. 
Indigenous  oases  of  bothriocephalus  infection  in  man  have  been  observed  in  northern 
Michigan.  See  Michigan  State  Board  of  Health  Report,  1912. 


142  LABORATORY    METHODS. 

water  .analysis.  Much  work  is  to  be  done  along  this  line,  and  a 
suspected  water  can  be  recommended  for  drinking  purposes  only 
when  the  analyst  can  say,  "There  are  no  typhoid  germs  in  this 
water,  and  under  present  conditions  none  can  find  their  way  into 
it. "  *  Such  a  recommendation,  coming,  however,  from  an  assistant 
in  some  water  laboratory  many  miles  away  and  from  the  examina- 
tion of  a  single  sample,  is  nothing  less  than  criminal. 

Sewage  Contamination. — On  the  other  hand,  a  physician  may 
condemn  a  water  as  quickly  as  an  expert,  provided  he  give  the  sub- 
ject a  little  study  and  make  analyses  with  sample  waters,  some  of 
which  are  known  to  be  pure  and  others  to  which  he  has  added  in 
small  amounts  sodium  chlorid,  feces,  urine,  old  manure,  etc. 

Sewage  contamination  may  be  proven  by  certain  inferences  de- 
duced from  the  sensible  combination  of  two  methods.  Just  which 
of  these  two  has  the  greater  value  can  not  be  proven  by  the  counter 
arguments  of  either  chemists  or  bacteriologists,  but  by  proper  con- 
clusions from  both.  Neither  is  infallible,  and  either  or  both  may, 
with  certain  restrictions,  prove  contamination  by  sewage,  and  the 
latter  condition  is  sufficient  to  condemn  any  water.  It  seems  ad- 
visable, in  the  first  place,  to  eliminate  certain  examinations  usually 
made  in  water  laboratories : 

1.  Odor.     May  be  noted,  but  it  is  well  to  remember  limitations. 

2.  Quantitative   determination  of  certain   chemical  constituents 
resulting  from  animal  refuse.     Where  fecal  contamination  occurs, 
pollution  by  the  urine  must  be  coincident,  and  urea  and  sodium 
chlorid  will  be  found.     The  decomposition  of  the  former  leads  to 
the  formation  of  various  ammonia  compounds,  the  amount  of  which 
will  vary  and  of  which  quantitative  estimations  may  be  made  witli 
difficulty.2     Their  presence  may  be  overlooked  if  the  estimation  of 
the  extra  chlorin  may  be  easily  made  and  if  the  value  of  this  esti- 
mation be  not  excessively  limited.     (See  page  143.) 

3.  Certain  other  considerations  of  scientific  interest,  but  of  no 
practical  importance. 

4.  Counting  bacteria  present.     This  may  have  some  significance 
when  the  presence  of  unusually  large  numbers  of  microorganisms 


1  The  attention   of  any  one   interested   in  isolating  tlie  typhoid   bacillus   from   drinking 
water  is  called  to  the  process  devised   by   .lurk son  and   Melia,   where  a   special  agar-agar 
is  used   in   its  cultivation.      An   account   of   tins  method  was  presented   to   the   American 
Public    Health    Association    at    Winnipeg    in    1908.      The    process    is    fully    described    in 
Leffmann's    "Examination   of   Water,''    January,    1909. 

2  To  quote   directly   from   Dr.   Leffmann's  preface   to  his  recent    (sixth)    edition   of  his 
book   on    water   analysis,    we   note   an    important    conclusion,    '  'The    figures   for  nitrogen 
or  ammonia  are   of  much   less  value   than  is  generally  supposed." 


SOME   SIMPLE   WATER   ANALYSES.  143 

is  noted,  but  even  this  does  not  attribute  any  specific  pathogenesis 
to  any  variety  present. 

5.  Determination  of  pathogenic  species  by  animal  inoculation. 
This  method  of  bacteriological  water  analysis,  devised  by  Vaughan, 
is  of  the  highest  value  when  searching  for  the  typhoid  and  colon 
germs,  but  can  not  be  considered  here. 

Comparative  Chlorin — Its  Definition. — It  is  not  sufficient  to 
draw  conclusions  from  the  amount  of  chlorin  in  a  given  water,  and 
this  is  one  of  the  instances  where  a  chemical  laboratory  at  a  dis- 
tance fails  to  give  valuable  evidence.  It  is  not  enough  to  make  a 
quantitative  estimation  of  a  certain  water,  but  calculations  should  be 
made  from  other  carefully  selected  waters,  at  least  five  in  number, 
representing  all  possible  sources  within  a  radius  of  ten  miles.  A 
careful  study  of  the  question  will  show  the  necessity  for  such  a  pre- 
caution. It  would  be  manifestly  unfair  to  condemn  a  water  in 
certain  localities  containing  much  chlorin.  The  ocean  may  not  be 
far  distant,  and,  moreover,  such  condition  might  be  explained  by 
certain  geological  formations.  An  analysis  of  a  water  one  mile 
distant  might  give  similar  results,  and  it  is,  therefore,  not  the 
actual  chlorin  increase,  but  the  comparative  chlorin  content — as 
compared  with  other  waters  in  that  section — of  the  sample  which 
determines  its  safety.  Two  wells  within  a  few  rods  of  each  other 
m;iy  each  show  large  amounts  of  chlorin,  and  the  question  will  be 
whether  both  are  contaminated  by  sewage.  Another  well  a  quar- 
ter* of  a  mile  away  may  show  considerable  less  salt,  as  geological 
formation  is  not  so  sharply  defined.  Samples  should,  however,  be 
taken  in  other  directions  before  conclusions  are  attempted,  and,  if 
the  chlorin  content  of  these  falls  short  of  those  noted  in  the  first 
two  wells,  it  is  quite  probable  that  the  latter  are  contaminated ; 
if  so,  compare  with  results  of  bacteriological  investigations  on  page 
146. 

Comparative  Chlorin — Its  Estimation. — At  least  four  waters  be- 
sides that  suspected  should  be  examined  before  an  opinion  is  given. 
As  the  physician  may  more  easily  obtain  such  samples  than  the 
laboratory  at  a  distance,  his  opinion  will  be  of  greater  value.  A 
careful  selection  of  these  samples  may  be  difficult,  but  none  the  less 
imperative.  "Level"  comparisons  as  well  as  "distance"  com- 
paiisons  are  of  value,  the  method  of  choosing  depending  on  the 
principles  outlined  above.  A  study  of  the  geological  survey  of  the 
region  in  question  may  be  advisable.  The  results  obtained  from 


144 


LABORATORY    METHODS. 


an  investigation  of  the  first  set  of  samples  may  call  for  an 
examination  of  other  waters  before  a  final  conclusion  can  be 
reached.1  The  following  apparatus  and  reagents  are  necessary : 


1.  Silver  nitrate  solution.2 

2.  Indicator^ 

3.  Two  large  tumblers  or  beakers. 


4.  Piece  of  white  paper. 

5.  Glass  stirring  rods. 

G.  Buret  as  used  in  gastric  analysis. 


Place  the  two  beakers  side  by  side  on  a  piece  of  white  paper. 
Add  to  each  exactly  100  cc.  of  the  water  and  10  drops  of  the  indi- 
cator. The  silver  nitrate  solution  is  added  drop  by  drop  from  the 
buret  into  the  beaker  until  a  slight  red  tint  is  noted  in  the  water, 
when  it  should  be  compared  with  the  control.  This  titration  is 
conducted  exactly  as  in  the  gastric  analysis,  each  drop  being  stirred 
into  the  water  and  the  reaction  given  time  to  take  place.  After  a 
little  practice,  less  than  five  minutes  will  answer  for  the  titration 
of  each  sample.  Readings  are  taken  on  the  buret  immediately  pre- 
ceding and  following  the  titration.  The  amount  in  cubic  centime- 
ters of  the  silver  nitrate  indicates  the  number  of  milligrams  of 
chlorin  in  the  water. 

Example. — If  2.5  cc.  of  silver  nitrate  are  used  for  the  100  cc.  of 
water,  this  sample  contained  2.5  milligrams  chlorin  (which  is  a 
very  good  average  in  some  regions). 

Now  titrate  in  the  same  manner  the  other  samples,  and  compare 
results  as  advised  above.  Does  the  sample  contain  too  much  chlorin 
— too  much  chlorin  as  compared  with  other  waters  of  that  re- 
gion? 

Comparative  Chlorin  Estimation — Principles  Involved. — The 
final  red  color  is  caused  by  the  chlorides  using  up  the  silver  solution 
as  long  as  they  are  present.  A  somewhat  less  affinity  is  shown  by 
the  indicator,  so  that  an  excess  of  the  reagent  causes  a  formation  of 
red  silver  chromate  and  proves  that  the  chlorin  has  been  consumed. 

Sources  of  Error. — The  "end  reaction,"  or  the  first  red  tint, 
may  be  difficult  for  the  beginner  to  recognize.  In  case  there  is  a 
question,  take  the  reading  and  then  add  1  or  2  drops  of  the  silver 


1  When  the  worker  becomes  sufficiently  acquainted  with  the  characteristics  of  the 
drinking  waters  in  his  vicinity,  and  has  determined  an  average  chlorin  or  a  standard, 
it  will  not  be  necessary  in  every  instance  to  run  control  tests. 

-  One  liter  of  distilled  water  contains  4.797  grams  of  chemically  pure  silver  nitrate, 
and  1  cc.  of  this  solution  is  equivalent  to  1  milligram  of  chlorin. 

3  One  hundred  cc.  of  distilled  water  contain  5  grams  of  pure  potassium  chromate. 
Add  some  of  the  silver  nitrate  solution  until  a  red  precipitate  forms,  and  filter.  This 
solution  serves  as  indicator.  Both  solutions  must  be  made  up  by  some  reliable  firm  or 
pharmacist. 


SOME   SIMPLE    WATER   ANALYSES.  145 

solution.  In  case  the  end  reaction  is  present,  the  mixture  will  be- 
come very  red,  and  it  b  a  good  plan  to  try  several  "knowns." 
For  example,  if  2  milligrams  of  sodium  chlorid  are  added  to  dis- 
tilled (chlorin  free)  water,  exactly  2  cc.  of  the  silver  solution 
should  cause  the  red  tint,  etc. 

Value  of  This  Estimation. — From  a  practical  standpoint, 
this  computation  is  of  great  value.  Although  a  scientific  analysis 
would  consider  ammonia,  nitrites,  and  several  other  estimations, 
it  rarely  takes  into  account  the  comparison  of  the  different  drink- 
ing water  sources.  As  contrasted  with  the  tests  to  follow  (page 
146),  chemists  and  bacteriologists  disagree.  Neither  is  infallible, 
and  each  helps  the  other.  It  is  a  question  of  personal  application, 
and  the  man  who  makes  both,  and  then  skillfully  interprets  results, 
gains  much  mere  than  he  who  spends  hours  in  the  determination 
of  hardness,  residue,  and  total  number  of  bacteria,  and  who  in  the 
end  can  not  conscientiously  attempt  a  conclusion. 

Limitations  of  This  Estimation. — The  estimation  of  chlorin 
forms  a  routine  procedure  in  most  water  laboratories,  and  the 
comparative  method  as  described  above  is  not  always  used.  The 
authors  have  used  it  successfully  in  several  problems  where  bacterio- 
logical examinations  appeared  to  be  of  secondary  consideration.  So 
far  as  the  simple  estimation  of  chlorin  is  concerned,  and  without 
reference  to  other  waters  of  the  region  in  question,  the  limitations 
are  so  many  as  to  render  the  value  and  rewards  of  such  labors 
practically  niL 

Bowel  Bacilli — Definition. — Some  bacteriological  method  should 
be  used  in  connection  with  the  chemical  procedures.  Of  these 
there  are  several  which,  with  certain  limitations,  may  be  employed 
advantageously  by  the  practitioner.  A  single  principle  is  involved 
in  their  application.  Where  fecal  contamination  is  present,  we 
should,  without  much  difficulty,  identify  certain  microorganisms 
whose  normal  habitat  is  the  bowel.  The  possibility  that  these  come 
from  the  alimentary  tract  of  other  animals  has  no  bearing  on  the 
question — a  solution  of  manure  was  never  intended  for  drinking 
purposes.  The  colon  bacillus,  at  least,  is  not  a  normal  inhabitant 
of  the  gut  of  a  fish  (Amyot),  and  it  is  the  identification  of  this 
microorganism  that  indicates  contamination  by  sewage. 

Identification  of  Colon  Bacilli. — Many  methods  have  been  de- 
vised, and  all  have  limitations  which  render  them  of  less  value  than 
may  be  desired,  yet,  when  skillfully  interpreted,  form  a  valuable 


146 


LABORATORY    METHODS. 


adjunct  to  the  comparative  chlorin  estimation.     Two  of  the  manv 
methods  are  presented,  with  respective  cautions  concerning  inter- 
pretation of  results,  and  either  or  both  may  be  used: 
Litmus  and  Gas  Method — Apparatus. — 


1.  Sterile  glucose  agar-agar  in  tube. 
(See  Searching  for  Germs,  page 
38.) 


•2.   Axolitniin,    sterile    1-percent 

otis  solution. i 
3.  Platinum  loop. 


METHOD.  The  tube  is  inoculated  with  about  2  cc.  of  the  sample 
water  according  to  the  methods  described  in  Searching  for  Germs, 
page  38.  The  agar  is  liquefied  and  the  sterile  azolitmin  added  and 
stirred  in,  about  5  drops  of  the  latter  being  usually  sufficient. 
When  the  temperature  of  the  water  bath  sinks  to  120°  F.,  the  in- 
oculation must  be  quickly  made.  Care  should  be  taken  to  avoid 
contamination  by  following  the  precautions  given  on  page  39. 
With  a  sterile  platinum  Icop  mix  well  the  sample  with  the  rapidly 
solidifying  media  and  keep  at  body  temperature  for  luriity-i'mir 
hours.  Reddish  colorations  or  evidences  of  gas  formation,  usually 
both,  may  be  caused  by  the  colon  bacillus. 

This  test  is  not  absolutely  conclusive  as  to  the  presence  of  the 
colon  bacillus,  but  is  valuable  when  used  in  connection  with  the 
comparative  chlorin  estimation.  The  tetanus  bacillus  may  cause 
gas  formation,  though  this  hardly  occurs  within  the  twenty-four 
hours.  The  typhoid  bacillus  may  cause  the  red  coloration,  but  this 
would  not  argue  in  favor  of  the  water. 

Fluorescence  and  Gas  Method — Apparatus. — 


1.  Sterile  glucose  agar-agar  in 


2.  Sterile    1-percent    solution    of    neuj 
tral   red.      (Griibler.) 


METHOD.  This  is  a  very  valuable  method,  and  in  a  large  ma- 
jority of  cases,  when  .positive,  points  conclusively  to  contamination 
by  the  colon  bacillus.  Several  anaerobes  give  the  reaction,  but  the 
typhoid  bacillus  does  not.  The  technic  is  identical  with  that  used 
in  the  litmus  test,  except  that  2  drops  of  the  neutral  red  solution 
are  used  instead.  The  colon  bacillus  produces  in  this  media  not 


1  Certain  precautions  are  necessary  when  attempting  the  sterilization  of  azolitmin 
and  other  delicate  chemicals,  as  rnutjttued  boiling  results  in  their  partial  disintcgra 
tion,  and  azolitmin  may  lie  decolorized,  although  some  of  the  original  color  may  !><• 
refrained.  The  colon  bacillus  should, iWft  ib*  present  if  pure  referents  and  sterile  water 
are  used,  and  neither  of  these  should  be  contaminated  by  handling,  but  a  little  heating 
is  the  safest  method.  It  forms  no  Snore's*,  und  is  usually  killed  below  170°  F. — i.  e., 
a  temperature  considerably  short  of  the  boiling  point. 


SOME   SIMPLE   WATER   ANALYSES.  147 

only  gas,  but  a  beautiful  lemon-yellow  color,  with  a  green  fluores- 
cence. The  fact  that  the  bacillus  of  hog  cholera  might  respond  to 
this  test  does  not  indicate  that  such  a  water  should  not  be  con- 
demned. 

Conclusions  from  a  Bacteriological  Examination. — Many  other 
methods  have  been  proposed  both  for  the  identification  of  the  colon 
bacillus  and  for  other  microorganisms  characteristic  of  sewage,  but, 
used  alone,  none  of  them  are  of  much  value.  When,  however,  the 
comparative  chlorin  is  high,  and  when  either  or  both  of  these 
bacteriological  tests  are  positive,  the  physician  may  safely  condemn 
the  water,  and  err  less  frequently  than  on  many  other  diagnostic 
questions.  When  the  chlorin  corresponds  with  that  in  other  wells 
of  that  locality  (see  Limitations,  page  145),  and  bacteriological 
tests  are  negative,  then  he  may  say,  "This  water  is  most  probably 
safe  for  drinking  purposes." 

Conclusion. — The  authors  believe  that  they  have  proven  their 
two  propositions,  and  recommend  these  examinations  to  the  physi- 
cian. In  case  assistance  is  necessary,  the  expert  should  not  be 
sent  a  sample  of  the  water,  but  should  be  called  to  the  "seat  of 
action,"  and  he  should  also  be  called  at  once  in  regard  to  the  more 
important  sanitary  questions  previously  mentioned  (page  139). 

A  full  and  scientific  examination  of  a  water  usually  confuses.  A 
sample  for  a  practical  analysis  should  not  be  sent  to  a  laboratory 
over  a  hundred  miles  away  for  the  following  reasons: 

1.  Certain  bacterial  changes  occur  during  transportation,   even 
where  ice  is  used.      (Jordon  and  Irons.) 

2.  An  investigation  of  a  single  sample  by  a  distant  laboratory 
is  subject  to  so  many  limitations  that  it  is  of  but  little  or  no  prac- 
tical value. 


CHAPTER  XIII. 

EVERY-DAY  STOOL  TESTS. 


Apparatus.— 


1.  Acetic  acid,  glacial. 

2.  Acetic  acid,  dilute. 

3.  Benzidin. 

4.  Evaporating  dish. 


5.  Glass  stirring  rod. 

G.  Hydrogen   dioxid. 

7.  Microscope   and   accessories. 


Stools  are  generally  so  offensive  that  their  examination  in  private 
practice  is  often  discouraging,  and  is  never  necessary  as  a  routine 
procedure.  Certain  symptoms  may,  however,  direct  attention  to 
the  matter,  and  it  is  then  that  an  inspection  or  a  chemical  test  may 
mean  much  in  a  diagnosis.  A  full  and  scientific  fecal  analysis  is 
rarely  of  use  outside  of  the  hospital.  The  physician  dreads,  and 
with  sufficient  reason,  a  necessary  test,  but  an  elevated  nose  never 
diluted  any  gas.  The  pathological  stool  is  not  usually  vile  smell- 
ing, while  that  of  the  person  without  ills  is  almost  unbearable. 
Many  interesting  examinations  have  been  omitted  simply  because 
they  are  not,  so  far  as  the  practitioner  is  concerned,  every-day 
tests. 

Obtaining  the  Specimen. — A  mere  inspection  cf  the  entire  stool 
is  sometimes  sufficient — as  when  looking  for  large  worms,  examina- 
tion of  infants'  stools,  etc. — but  for  chemical  and  microscopical 
tests  small  samples  containing  mucus  or  bits  of  blood  are  selected, 
and  these  may  be  carried  to  the  office  in  a  tightly  corked  bottle,  the 
mouth  of  which  is  sufficiently  wide  to  permit  the  entrance  of  in- 
struments. If  a  search  is  to  be  made  for  the  ameba  coli,  .the  speci- 
men must  be  kept  warm  until  examination  of  the  living  animal  is 
completed.  Bits  of  material  may  be  transferred  to  the  test  tube 
or  slide  with  a  pipette  or  platinum  loop.  Such  examination  may 
be  made  after  office  hours,  and  suitable  methods  of  deodorizing  em- 
ployed. (See  page  194.)  Smears,  after  fixation,  give  off  no  odor, 


References. — Sahli,    Wood,    Boston,    Webster,    Simon,    and    other    works    on    clinical 
diagnosis. 

148 


EVERY-DAY   STOOL   TESTS.  149 

and  may  be  examined  the  following  day  in  case  good  artificial 
light  is  not  available  at  the  time. 

Odor. — This  is  of  little  diagnostic  import.  There  may  be  little 
or  no  odor  in  starvation  and  certain  chronic  diseases,  but  the  odor 
of  a  meat  diet  is  most  marked. 

Color. — The  following  table  gives  the  colors  most  likely  to  be  met 
in  the  stool  of  the  adult: 

Color.  Etiology. 

Brown,  various  shades Normal. 

Dark-brown      Meat  diet. 

Gray  or  clay-colored Obstructive  jaundice,  fatty  diarrhea, 

etc. 

Light-yellow  Exclusive  milk  diet,  large  amounts  of 

starches,  santonin,  rhubarb,  senna. 

Red    : Fr:3h  blood,  hematoxylin,  in  frauds. 

Tarry-black    Blood. 

Granular-black    Bismuth,  iron,  and  manganese. 

Green  Calorie],  spinach,  lettuce,  parsley,  in- 
fections with  bacillus  pyocyaneus,  etc. 

Blue  or  green  on  standing Methylene  blue. 

Violet    Santa!  oil. 

Consistency. — The  consistency  of  an  adult's  stool  is  so  variable 
as  to  be  of  little  value  in  diagnostic  procedures,  and  depends  mainly 
on  the  amount  of  water  present.  Fc^-  the  differentiation  between 
pus  and  mucus  see  The  Sputum,  page  27. 

Test  for  Occult  Blood. — Dissolve  about  1  grain  of  benzidin  in 
about  %  dram  of  glacial  acetic  acid.  Stir  into  y2  dram  of  dilute 
acetic  acid  about  2  grains  of  the  feces,  and  to  3  drops  of  this  re- 
sulting liquid  add  20  drops  of  3-percent  hydrogen  dioxid  and  20 
drops  of  the  benzidin  solution.  Stir  the  mixture,  and,  if  blood  is 
present,  a  green  or  blue  coloration  soon  results.  This  will  identify 
very  small  amounts  of  blood.  Bleeding  adenoids  must  be  ruled 
out,  and  foods  containing  meat  should  not  be  allowed  for  several 
days  preceding  the  test.  It  is  usually  a  waste  of  time  to  attempt 
the  identification  of  fecal  blood  by  the  presence  of  red  corpuscles 
unless  they  occur  in  very  large  amounts. 

Searching  for  Bacteria. — As  a  routine  procedure,  this  is  of  little 
practical  value  because  of  the  enormous  numbers  and  varieties  of 
germs  normally  present.1 


1  Of  these  enormous  numbers  it  seems  safe  to  say  that  over  75  percent  are  dead  and 
20  percent  are  attenuated  or  incapable  of  growing  rapidly  in  the  fores.  A  few.  how- 
ever, notably  the  colon  bacillus,  may  cause  widespread  mischief  when  given  a  chance, 


150  LABORATORY    METHODS. 

Searching  for  Ameba  Coli. — The  sample  must  be  kept  warm,  as 
it  is  often  difficult  to  identify  the  amebae,  except  by  the  motions  of 
their  pseudopods,  and  this  activity  ceases  below  75°-80°  F.  The 
protrusion  of  a  pseudopod  is  not  a  rapid  process,  and  it  is  not 
usually  observed  with  the  eye,  but  with  the  aid  of  a  series  of  rough 
drawings,  one  of  which  is  taken  every  thirty  seconds.  A  compari- 
son of  these  may  show  that  a  change  in  shape  has  actually  oc- 
curred. The  ameba?  may  often  be  differentiated  from  epithelial 
cells  on  account  of  their  light-green  tint  and  because  they  are  likely 
to  contain  leukocytes,  bacteria,  particles  of  food,  etc.,  in  the  cyto- 
plasm. 

Detection  of  Koch's  Bacillus. — The  diagnosis  of  intestinal  tuber- 
culosis by  the  identification  of  the  specific  bacillus  is  subject  to 
various  limitations,  as  tuberculous  sputum  may  be  swallowed,  and, 
unless  clinical  symptoms  are  sufficient  to  justify  such  an  examina- 
tion, conclusions  may  be  very  misleading.  As  in  the  pulmonary 
form,  there  is  a  presloughing  stage,  when  few  or  no  bacilli  are  loos- 
ened into  the  lumen  of  the  intestine.  In  acute  miliary  forms  death 
may  occur  before  any  ulcers  have  formed.  A  positive  test  for 
occult  blood  may  be  the  first  sign  that  the  mucosa  has  become 
necrotic,  although  bacilli  usually  begin  to  appear  in  the  feces  at 
this  time.  There  are  also  normally  many  acid  fast  bacilli  in  the 
stools  of  an  adult,  notably  the  timothy  bacillus,  and  these  may  be 
differentiated  from  Koch's  bacillus  by  the  use  of  the  hydrochloric 
alcohol  solution.  (See  The  Urine  in  Disease,  page  123.)  The  tu- 
bercle bacillus  is  most  likely  to  be  found  in  the  mucous,  purulent, 
or  blood-stained  particles.  For  its  identification  see  The  Sputum, 
page  32. 

Searching  for  Pinworms. — These  may  be  visible  at  the  anus, 
clinging  to  the  lowest  mucosa  or  hairs,  and  have  the  appearance  of 
long  white  crystals  of  hoarfrost.  The  first  bowel  movements  are 
most  likely  to  contain  them,  but  never  contain  their  ova.  They 
give  rise  to  local  disturbances,  and  may  usually  be  identified  with- 
out the  use  of  enemata. 

Searching  for  Ascaris  Lumbricoides. — This  occurs  in  the  small 
intestine,  but  is  rarely  passed,  as  it  holds  fast  to  the  intestinal  wall 
by  means  of  spiral  turns.  When  found,  it  may  be  identified  by  its 
smooth  appearance  and  its  light-brown  or  flesh  color.  It  is  usually 
the  length  of  an  ordinary  lead  pencil,  and  tapers  to  points  at  both 
ends.  Its  ova  are  often  found  in  the  feces,  and  are  elliptical  in 


EVERY-DAY   STOOL   TESTS. 


151 


form,  with  a  hard  shell,  which  is  surrounded  by  an  albuminous 
covering-. 

Many  physicians  desire  to  save  specimens  of  these  worms,  and  the 
following  technic  will  give  the  best  results:  Kill  in  70-percent 
alcohol  heated  to  about  175°  F.,  permit  to  cool,  and  transfer  to 
preserving  fluid  made  up  of  70  parts  absolute  alcohol,  5  parts 
glycerin,  and  25  parts  distilled  water. 

Searching  for  Tapeworms. — Segments  frequently  occur  in  the 
feces.  The  ova  are  globular  and  are  covered  with  thick  capsules. 
It  would  seem  that  the  morphology  is  so  characteristic  that  the 


Pig.   33. — Tapeworms  compared  with  vegetable  fibers.      A,   B,  magnified   segments  of 
small  tapeworn.h  :   (.',  magnified  banana  fibers,  recovered  from  stools  of  an  infant. 

confusion  of  tapeworm  segments  with  other  elements  would  be 
impossible,  and  it  is  safe  to  say  that  a  tapeworm  is  rarely  mistaken 
for  anything  else.  It  is,  however,  often  surprising  to  find  how 
closely  certain  vegetable  fibers  resemble  the  segments  of  small 
tenhi',  of  which  the  banana  furnishes  an  example. 

Tapeworms  may  be  killed  and  preserved  as  follows:  "Wash  in 
water,  being  careful  not  to  break  the  worm.  Kill  in  equal  parts  of 
a  saturated  aqueous  solution  of  mercuric  chlorid  and  70-percent 
alcohol,  to  which  has  been  added  1  percent  (of  the  entire  volume) 


152 


LABORATORY    METHODS. 


glacial  acetic  acid.  Heat  to  160°  F.  and  cool.  Wash  gently  in 
running  water,  and  remove  excess  of  mercury  with  iodin  alcohol. 
Eubber  gloves  should  be  worn  to  prevent  cysticercus  infection. 
Specimens  may  be  preserved  as  described  for  ascaris  lumbric- 
oides,  page  151. 

Tapeworms  may  be  stained  and  mounted  on  slides  by  the  follow- 
ing method:  After  killing,  flatten  gently  between  two  slides  held 
together  with  a  rubber  band,  and  stain  in  carmine  about  six  hours. 
Remove  from  between  slides  and  decolorize  in  alcohol,  occasionally 
examining  the  specimen  under  low-power  objective  until  a  suitable 
picture  is  obtained.  Transfer  to  95-percent  alcohol  and  then  to 


100 

Microns. 


o 


Fig.  34. — Ova  of  the  most  common  intestinal  worms  compared  with  a  red  blood  cell.  A, 
ovum  of  hookworm,  thin  shell  containing  segment  ing  or  segmented  material:  B,  ovum 
of  tapeworm,  thick  horny  shell;  C,  ovum  of  round  worm,  thick  shell  surrounded  by 
albuminous  capsule;  D,  erythrocyte. 

absolute  alcohol  in  order  to  remove  water.  Clear  in  carbol-xylol 
and  mount  in  balsam.  If  aqueous  carmine  rather  than  the  alco- 
holic solution  is  used,  it  will  not  be  necessary  to  compress  specimen 
until  after  decolorization. 

Searching  for  the  Hookworm. — The  adult  parasites  are  some- 
times found  in  the  stools,  but  generally  a  search  must  be  made  for 
the  ova,  which  are  usually  discharged  as  segmented  masses,  re- 
sembling a  small  bunch  of  large  grapes  inclosed  within  a  thin  shell. 
In  cases  of  "southern  anemia,"  where  neither  hookworms  nor 
their  ova  are  found,  a  test  should  be  made  for  occult  blood  accord- 
ing to  previous  directions  (page  149).  This  condition  is  caused 


EVERY-DAY   STOOL   TESTS.  153 

by  the  hemorrhage  of  the  mucosa  continuing  after  the  hookworm 
lias  departed  to  some  other  portion  of  the  gut. 

Comparison  of  the  Common  Ova. — There  is  hardly  any  need  for 
contrasts  when  the  symptomatology,  geographical  distribution,  and 
other  factors  are  considered.  Ova  of  worms  are  transparent  or  of 
a  brown  color  when  within  the  body  of  the  female  parasite,  but 
when  passed  by  the  bowel  are  yellow  or  brown  because  of  the  uro- 
bilin  present.  The  smallest  of  these  has  a  diameter  three  times  that 
of  the  red  blood  cell,  while  many  are  even  larger  than  epithelial 
cells.  They  should  not  be  confused  with  the  latter  because  of  cer- 
tain characteristics  that  are  absent  in  all  epithelial  cells,  but  some 
of  which  may  be.  seen  in  any  of  the  ova.  These  characteristics  are 
their  elliptical  form  of  almost  geometric  regularity,  presence  of  a 
capsule  which  may  in  some  of  the  eggs  become  quite  thick,  and 
tendencies  to  segmentation  within  this  shell. 

Fecal  Findings  in  Several  Conditions. — 

1.  Starvation.     Little  or  no  odor ;  formed  stools. 

2.  Vegetable  diet.     Light-brown  color,  or  even  green  when  fresh 
vegetables  are  used. 

3.  Milk  diet.     Light-yellow  color,  with  but  little  odor. 

4.  Meat  diet.     Dark  color  and  very  marked  odor. 

5.  Constipation.     The  typical  stool  is  very  hard,  dry,  and  often 
void  of  odor;  shows  a  tendency  to  crumble.     Curiously  enough, 
watery  stools  are  sometimes  observed  in  costiveness. 

6.  Mucous  colitis.     Intestinal  mucus  occurs  normally  in  small 
amounts,  but  is  increased  in  most  pathological  conditions.     As  it 
is  easily  digested,  it  comes  from  the  upper  bowel  only  in  cases  of 
marked   diarrhea.     Mucus   is  usually  jelly-like  in   character,   but 
may  appear  as  leathery  masses,  or  even  as  casts  of  the  gut.     The 
particles  may  resemble  pieces  of  asparagus  or  intestinal  worms. 
The  mucus  of  an  inflammation  is  easily  differentiated  from  that 
of  a  truly  nervous  condition,  as  the  former  contains  inclusions  of 
cells  or  food,  while  the  latter  does  not. 

7.  Internal   injuries.     Surgeons   watch   with   interest   the   first 
urine  and  feces  of  emergency  cases  for  signs  of  blood. 

8.  Typhoid.     "Pea  soup"  feces  of  an  offensive  odor,  and  con- 
taining in  small  amount  pus,  necrotic  tissue,  and  sometimes  blood. 

9.  Tuberculosis,  carcinoma,  etc.     Blood,  pus,  etc. 

10.  Dysentery.  "Watery"  feces,  containing  necrotic  tissue, 
amebae,  and  blood. 


154  LABORATORY    METHODS. 

11.  Cholera.     "Rice  water"  stools,  which  late  in  the  disease  may 
he  practically  a  suspension  of  vibrios  in  blood  serum. 

12.  Lienteric  diarrhea.     Much  undigested  food  and  little  mucus. 

13.  Colonic  diarrhea.     Little  undigested  food  and  much  mucus. 

14.  Drug  administration.     (See  color  of  feces,  page  149.) 

15.  Obstructive  jaundice.     The  clay-colored  stools  are  not  due  so 
much  to  the  absence  of  bile  pigments  as  to  the  great  increase  of 
undigested  fats  and  soaps. 

Stools  of  an  Infant. — Within  the  first  twenty- four  hours  the 
dark-brown  or  black  meconium  should  be  passed.  The  stool  of  a 
milk  diet  is  unformed,  of  a  butter-like  consistency,  and  of  a  light- 
yellow  color.  There  are  many  variations  from  this  type,  none  of 
which  can  be  considered  pathological  unless  symptoms  of  disease 
or  disorder  are  present,  a  point  that  is  often  overlooked.  Any 
variations,  however,  from  the  typical  milk  stool  occurring  in  con- 
nection with  illness  on  the  part  of  the  infant  become  at  once  of 
the  greatest  diagnostic  and  prognostic  importance.  For  example, 
a  cheesy  stool  in  a  healthy  infant  means  nothing,  showing  only  an 
excess  of  undigested  casein,  and  does  not  indicate  drugs  or  diet 
changes,  but,  should  a  severe  diarrhea  accompany  or  immediately 
follow  the  appearance  of  these  white,  lumpy  stools,  the  indication 
is  then  clear — barley  water  or  a  reduction  of  proteids.  Keeping  in 
mind  this  limitation,  the  following  table  is  given : 

Appearance  of  infant's  stool.  Significance    (morbid  only  when  certain 

symptoms  justify). 

Pink    streak    Uric    acid    infarct     (contamination    by 

urine). 

White   and   cheesy Undigested  casein. 

Gray    Obstructive  jaundice,  excess  of  fat. 

Green     Cbanged  bile  pigments. 

Curds,     colic,     with      constipation     or 

diarrhea    Proteids  at  fault. 

Green    or    greenish-yellow,    sour,    with 

loose   bowels    Fats  or  sugars,  usually  the  former  at 

fault. 

Mucus Malnutrition,  or  accompanies  severe  in- 

totinal   inflammation. 

Red    Blood  from  lower  alimentary  tract. 

Brown     Blood  from  upper  alimentary  tract. 

An  inspection  of  the  napkin  is  usually  sufficient,  and  an  occult 
blood  test  may  be  occasionally  indicated.  Fatty  acids  may  appear 
as  lump-like  masses,  and  are  sometimes  mistaken  for  undigested 


EVERY-DAY   STOOL   TESTS.  155 

casein.  The  former  are,  however,  quickly  dissolved  by  ether,  which 
may  be  strained  away  from  the  stool  proper,  to  reappear  when  the 
ether  evaporates. 

Tampering1  with  the  Stool. — The  "  worm  faker,"  in  times  past, 
reaped  a  rich  harvest  from  his  victims.  When  teniae  were  not  ob- 
tainable, earthworms,  grubs,  and  centipedes  answered  equally  well. 
A  western  "expert"  used,  with  astounding  success,  a  pickled  spinal 
cord  with  its  branches,  and  hundreds  of  grateful  persons  passed 
this  single  specimen.  Eventually,  however,  skeptics  began  to  find 
fault  with  the  darkened  bed-chamber,  persons  became  enlightened, 
and  vegetable  fibers  or  other  bits  of  extraneous  matter  were  picked 
out  and  shown  'under  a  microscope.  The  claim  has  been  made  that 
certain  drugs  are  capable  of  dissolving  many  of  these  worms  within 
the  bowel,  but  often  the  object  is  to  deceive. 

The  pseudo-gallstone  seems  of  late  to  have  become  prominent. 
Olive  oil  or  similar  fatty  bodies  are  sent  to  the  victim,  who  is  urged 
to  take  the  prescribed  substance  in  large  doses,  and  advised  to  make 
frequent  .examinations  of  the  bowel  discharges.  He  soon  begins 
to  find  large  soft  and  greasy  lumps,  which  may  be  white,  but  are 
usually  green  if  the  bile  ducts  are  not  occluded,  and  consist  of  fats, 
fatty  acids,  and  certain  soaps.  The  dupe  rushes  wild-eyed  to  the 
local  physician,  w7ho  too  often  agrees  that  biliary  calculi  have  been 
passed.  A  second  thought,  or  indeed  a  brief  study  of  the  appear- 
ance of  gallstones,  would  at  once  expose  the  imposition.  Hema- 
toxylin  may  color  the  feces  a  bright-red,  and  should  cause  no  more 
concern  than  a  methylene-blue-laden  urine. 

Less  Frequently  Applied  Tests. — Certain  dietetic  tests  and  dif- 
ficult bacteriological  searches,  as  well  as  certain  scientific  examina- 
tions, are  omitted,  as  a  study  of  the  various  crystals  and  cells  in 
feces  may  prove  a  waste  of  time  to  the  practitioner. 

Value  and  Limitations  of  Stool  Analysis. — Many  of  these  limi- 
tations have  been  pointed  out,  and  in  selected  cases  the  value  of 
certain  searches  is  so  well  understood  that  emphasis  is  unnecessary. 
A  routine  stool  examination  in  every  case  of  sickness  is  wrorse  than 
a  waste  of  time  to  the  physician.  If,  however,  certain  symptoms 
lead  him  to  suspect  the  presence  of  blood  or  parasites,  or  the  infant 
seems  to  be  slowly  starving  to  death,  and  he  fails  to  make  the  few 
necessary  investigations  into  the  character  of  the  stools,  he  ceases 
to  deserve  not  only  the  name  "diagnostician,"  but  also  "thera- 
peutist." 


CHAPTER  XIV. 

TECHNIC  OF  THE  PRIVATE  POST-MORTEM. 

Equipment. — A  complement  of  autopsy  tools  may  be  selected 
from  the  surgeon's  hand-bag  and  a  carpenter's  kit,  consisting  of  a 
cartilage  knife  or  heavy  scalpel,  amputating  knife,  large  shears, 
probe  point  shears,  surgical  saw,  bone  forceps,  chisel,  hammer, 
bone  drill  for  wiring  skull  cap  into  place,  and  wire,  sutures, 
needles,  probes,  tissue  forceps,  etc.  A  pair  of  scales  and  a  foot- 
rule  should  be  included  if  possible.  The  high-priced  post-mortem 
set  offers  no  advantages  over  this  selection  so  far  as  the  private 
examination  is  concerned. 

Private  Post-Mortem. — The  complete-  autopsy  is  rarely  con- 
ducted in  private  practice,  and,  so  far  as  the  various  lines  of  re- 
search are  concerned,  the  clinic  will  continue  to  offer  greater 
advantages  than  may  be  obtained  by  the  general  practitioner,  but 
this  does  not  indicate  that  the  private  post-mortem,  incomplete 
though  it  may  be,  is  wholly  without  a  science.  An  indiscriminate 
slashing  may  demonstrate  but  little,  while  a  few  well-selected, 
though  crude,  dissections  may  reveal  all  that  is  desired  to  be 
learned.  No  pathology  can  be  included  in  this  book,  except  so  far 
as  elucidation  of  details  in  technic  is  necessary.  The  description 
given  is  essentially  that  offered  by  Warthin  and  other  experts  in 
this  branch  of  medicine,  modified  only  where  it  is  necessary  to 
meet  the  needs  of  the  average  practitioner. 

Precautions.— 

1.  Even  though  the  relatives  request  the  autopsy,  a  written  per- 
mit is  always  necessary,  and  such  permit  may  be  given  by  the  fol- 
lowing persons  in  the  order  named:  (1)  husband  or  wife, 

(2)   children,    (3)   mother,    (4)    father,    (5)    brothers,  sisters,  and 

(6)  other  relatives. 

2.  In  case  of  uncertainty  as  to  the  cause  of  death,  and  if  an 
autopsy  is  forbidden  by  relatives,  the  coroner  is  notified.     In  case 


References. — Warthin:    Practical    Pathology;    Cattell :    Post-Mortem    Pathology;    Mai- 
lory  and  Wright:   Pathological  Technic;   Box:    Post-Mortem  Technic. 

156 


TECHNIC   OF   PRIVATE   POST-MORTEM.  157 

of  absence  of  the  latter,  the  physician,  some  courts  have  decided, 
may  stop  funeral  preparations  and  proceed  on  his  own  authority 
to  ascertain  the  cause  of  death,  even  though  he  must  resort  to  an 
autopsy. 

3.  No  unnecessary  mutilation  of  the  cadaver  is  allowable.     If 
necessary,  small  bits  of  tissue  may  be  reserved  for  histological  ex- 
amination. 

4.  The  presence  of  unprofessional  persons  is  debarred  by  law, 
but  medical  students  may  attend. 

Such,  briefly,  are  the  usual  legal  precautions.  In  private  au- 
topsies, however,  certain  considerations  should  be  shown  the  rela- 
tives and  friends,  who  may  be  waiting  for  the  funeral  services  to 
proceed,. and  these  considerations  may  be  briefly  outlined  as  fol- 
lows: 

1.  Provide  for  the  disposal  of  blood  and  other  waste  without 
being  seen  by  the  mourners.     Suspicious  material  should  be  thor- 
oughly mixed  with  disinfecting  solutions  and  buried. 

2.  Perform  the  work  quietly. 

3.  Avoid  odors  by  burning  coffee,  sugar,  rags,  or  tobacco. 

Preparations. — Gowns  and  rubber  gloves  should  be  worn  if  pos- 
sible, and  strict  antiseptic  methods  followed.  It  is  not  advisable 
for  obvious  reasons  to  use  the  dining-room  table.  A  work-bench, 
or  some  rough  boards  supported  by  chairs  or  trestles,  answer  very 
well.  A  canvas  cot  covered  with  oilcloth  has  been  used,  and  blocks 
or  bricks  placed  under  the  legs,  but  this  support  is  not  satisfactory 
when  sawing  the  skull  cap.  The  floor  should  be  covered  with 
several  thicknesses  of  paper  to  avoid  soiling.  Plenty  of  cold,  clean 
water  should  be  at  hand,  and  warm  water  is  preferable  when 
washing  up  after  the  autopsy.  The  cadaver  should  be  entirely 
stripped  if  possible.  For  the  treatment  of  wounds  obtained  during 
autopsies,  see  Laboratory  Prophylaxis,  page  179. 

Bacteriological  Evidences  of  Disease. — So  much  information 
may  be  obtained  by  certain  examinations  during  life,  that  it  is 
advisable  that  these  be  not  deferred  until  too  late  to  use  the  in- 
formation in  therapeutic  procedures,  as  often  nonpathogenic  germs 
are  already  emigrating  from  the  intestines  into  the  tissues  before 
the  final  breath  of  life  leaves  the  body. 

Microscopic  Morbid  Anatomy. — Minute  inspections  are  often 
necessary  to  clear  questionable  points,  and  the  microscope  is  then 
called  into  requisition.  Small  bits  of  organs  may  be  dropped  into 


158  LABORATORY   METHODS. 

formalin  or  alcohol,  and  examined  at  leisure  according  to  directions 
in  Essence  of  Tissue  Diagnosis,  page  78. 

Weights  and  Measures. — Increase  of  weight  accompanies  the 
congestion  of  various  organs.  Certain  atrophies  and  hypertro- 
phies may  cause  alterations,  often  strikingly  apparent,  but  whii-h 
may  be  evident  to  the  nonexpert  only  by  the  proper  use  of  scales 
and  foot-rule.  To  obtain  a  dimension,  thrust  a  hat  pin  through 
the  desired  portion  of  the  organ,  and  read  the  result  by  applying 
the  foot-rule.  If  desirable,  measurements  may  be  made  with  a 
pelvimeter.  The  following  table,  taken  mainly  from  "Warthin's 
Protocol,"  gives  average  normal  weights  and  dimensions,  but  the 
English  system  is  used  where  possible: 

Length  of  male   cadaver     70     inches. 

Length  of  female  cadaver    61     inches. 

Weight  of  male   cadaver    2,344     ounces. 

Weight  of  female  cadaver     1,875     ounces. 

Circumference  of  skull  cap 20  to  30     inches. 

Longitudinal  diameter  of  skull   cap 7.5  inches. 

Transverse  diameter  of  skull  cap 6     inches. 

Weight  of  male  brain 42.5  ounces. 

Weight  of  female  brain    39     ounces. 

Weight  of  male  cerebrum     36     ounces. 

Weight  of  female  cerebrum    32.5  ounces. 

Weight  of  male  cerebellum    4.5  ounces. 

Weight  of  female  cerebellum     4   ounces. 

Weight  of  spinal  cord About     1     ounce. 

Length  of  spinal  cord     About  18     inches. 

Weight  of  male  heart   9.5  ounces. 

Weight  of  female  heart    8     ounces. 

Size  of   heart. .  .Usually  that  of  right  clenched  fist  of  individual. 

Size  of  mitral  valve    Admits  2      fingers. 

Size  of  tricuspid  valve    Admits  3      fingers. 

Size  of  pulmonary  valve  Admits  1.5  fingers. 

Size  of  aorta      Admits  thumb. 

Thickness  of  wall  of  right  ventricle 2  to     3  millimeters. 

Thickness  of  wall  of  left  ventricle 7  to  10  millimeters. 

Weight  of  left   lung     10  to  15     ounces. 

Weight  of  right  lung  11  to  16     ounces. 

Weight  of  thyroid     1  to     2     ounces. 

Weight  of  thymus  at  birth 1/3  ounce. 

Weight  of  thymus  at  puberty  (disappears  after  age  25)  .  %  ounce. 

Weight  of  spleen 5  to  8     ounces. 

Size  of  spleen   5x2x1     inches. 

Weight  of  liver..  ..50  to  63     ounces. 


TECHNIC   OF   PRIVATE  POST-MORTEM.  159 

Size  of  liver 10x12x4     inches. 

Weight  of  pancreas 3  to  4     ounces. 

Size   of   pancreas 9x2x2     inches. 

Weight  of  adrenals   1  to  2     drams. 

Weight  of  right   kidney    4.5  ounces. 

Weight  of  left  kidney Little  over  5     ounces. 

Weight  of  prostate     About  5     drams. 

Weight  of  resting  uterus 1  to   1.5  ounces. 

Weight  of  gravid  uterus   Very  variable. 

Weight  of  virgin  ovaries 3     drams. 

Weight  of  adult  ovaries    2     drama. 

Cortex  of  kidney  is  about  %  inch  in  thickness. 

Kidney  glomeruli  are  red  and  about  the  size  of  pin-points,  being 
slightly  elevated  above  the  surface. 

Splenic  follicles  are  about  the  size  of  a  medium  brass  pin- 
head,  gray,  and  not  elevated. 

Uterus  wall  is  about  %  to  1  inch  in  thickness. 

Gall  bladder  wall  is  about  1  to  2  millimeters  in  thickness. 

Order  of  Procedure. — A  systematic  technic  is  desirable,  and,  in 
case  only  portions  of  the  body  .are  to  be  examined,  the  following 
order  may  be  accordingly  modified : 

1.  Inspection,  palpation,  and  percussion. 

2.  Head. 

3.  Opening  of  trunk. 

4.  Heart  is  examined  before  the  lungs  in  order  to  preserve  the 
relation  and  position  of  soft  clots,  etc.,  which  might  otherwise  be 
drained  away. 

5.  Lungs. 

6.  Neck  and  thoracic  vessels. 

7.  Spleen. 

8.  Kidneys  and  adrenals. 

9.  Stomach  and  intestines. 

10.  Liver. 

11.  Pancreas. 

12.  Great  vessels. 

13.  Pelvic  viscera. 

14.  Spinal  cord.     If  only  the  cord  is  to  be  examined,  it  may  be 
removed  from  the  back  (page  168). 

15.  Joints,  lymph  glands,  etc. 

Clinical  opinions  are  of  little  worth  so  far  as  an  actual  gain  in 
medical  knowledge  is  concerned,  and  the  autopsy  should  be  ap- 
proached with  the  expectation  of  finding  every  pathological  possi- 


160 


LABORATORY    METHODS. 


bility.  The  circumstances  of  the  case  may  not,  however,  permit 
such  procedure,  as  the  relatives  may  consent  to  an  examination 
of  only  the  kidneys  for  evidences  of  Bright 's  disease,  etc.  In  sus- 
pected Addison's  disease  or  gastric  conditions  the  adrenals  and 
stomach  should  be  examined  as  early  as  possible,  as  autolysis  often 
rapidly  proceeds  in  these  organs  after  death. 

Inspection,  Palpation,  and  Percussion. — Inspection  serves  to 
reveal  not  only  the  changes  due  to  the  cessation  of  the  respiration 
and  circulation,  but  may  often  show  the  cause  and  circumstances 
of  death,  or  give  other  evidence  in  regard  to  the  nature  of  the  fatal 
disease.  It  may  be  too  late  for  a  complete  physical  examination, 
but  a  consulting  physician  may  nevertheless  be  justified  in  hastily 
palpating  and  percussing  the  cadaver. 


Fig.  35. — Scalp  incision.  The  scalp  incision  must  be  made  in  the  dorsum  in  order  that 
it  may  not  be  visible  at  the  funeral.  It  extends  from  ear  to  ear  and  compU-ics  the 
largest  occipital  circumference. 

Uncovering  the  Brain. — The  cadaver  is  laid  on  its  back,  and  its 
hands  placed  under  the  buttocks  in  order  to  prevent  their  dangling 
over  the  edges  of  the  table.  A  block  should  be  placed  under  the 
neck  or  head  in  such  a  manner  that  the  head  is  raised  high  from 
the  table,  the  vertex  pointing  upward.  The  hair  is  wetted  and 
parted  in  such  a  manner  as  to  expose  the  line  of  the  initial  incision. 
The  dorsum  is  selected  for  the  incision  in  order  that  no  marks  can 
be  observed  at  the  funeral,  extending  from  ear  to  ear  and  com- 


TECHNIC   OF   PRIVATE   POST-MORTEM.  161 

pleting  the  greatest  occipital  circumference.  If  desired,  the 
cadaver  may  be  rolled  on  its  belly  while  the  incision  is  being  made 
(Fig.  35),  or,  if  left  supine,  the  head  should  be  raised  as  directed 
above. 

The  cut  should  extend  to  the  periosteum,  and  may  be  made  with 
scalpel  or  cartilage  knife.  The  anterior  flap  is  pushed  forward 
and  hooked  under  the  chin.  The  origin  of  each  temporal  muscle 
is  removed  by  a  semicircular  incision  and  peeled  downward.  The 
periosteum  may  be  removed  prior  to  opening  the  skull  cap  if  so 
desired.  During  these  operations  and  others  which  may  follow 
the  prosector  should  be  on  the  lookout  for  evidences  of  disease,  and 
hair,  scalp,  muscles,  and  periosteum  should  be  subjected  to  a  rigid 
inspection. 

Some  operators  prefer  to  remove  the  entire  skull  cap  by  a  cir- 
cular cut.  The  angular  cut,  however,  offers  many  advantages, 
and  is  recommended  by  competent  authorities.  The  angular  cap  is 
more  easily  replaced  in  its  natural  position,  and  is  less  likely  to 
present  at  the  funeral  a  frontal  line  or  joint  beneath  the  skin. 
The  angular  cut  is  not  nearly  so  difficult,  and  is  much  more  cleanly 
because  of  the  absence  of  hypostatic  blood.  It  may  begin  at  the 
forehead  as  a  circular  incision,  but  is  discontinued  at  the  aural 
lines,  and  from  these  points  two  posterior  oblique  cuts  extend 
upward  and  cross  just  dorsal  to  the  posterior  fontanel,  forming 
an  acute  angle  (Fig.  36). 

The  left  hand  may  anchor  the  head  of  the  cadaver  with  the 
anterior  flap,  while  the  right  hand  uses  the  saw.  A  long  stroke 
quickly  minces  the  cerebral  surface,  affording  but  a  short  slit  into 
the  cranial  vault,  and  it  is  therefore  advisable  to  saw  on  the  most 
convex  surface  of  the  bone.  A  very  short  stroke  is  imperative. 

Unless  the  dura  is  greatly  distended  by  fluid,  or  is  adherent  as 
in  babes  and  the  aged,  there  is  no  excuse  for  cutting  it.  A  slight 
loss  of  resistance  indicates  the  necessity  of  an  exploratory  probe. 
The  sawdust  is  white,  then  red,  and  again  white,  as  the  tables  are 
respectively  reached,  and  the  dura,  when  touched,  may  give  forth 
a  sound  not  unlike  that  of  a  dry,  rustling  leaf.  When  the  probe 
indicates  that  the  sawing  has  been  finished,  insert  a  chisel  in  the 
right  temporal  region,  making  a  quick  turn.  The  fingers  are  in- 
serted and  the  piece  of  bone  pulled  back,  the  dura  stripping  slowly 
and  always  adhering  at  the  longitudinal  sinus. 

Examination  of  Meninges. — To  measure  the  intradural  tension, 


162 


LABORATORY    METHODS. 


attempt  to  pick  up  one  fold  over  the  frontal  lobe,  which  picking 
up  will  be  impossible  if  the  tension  is  increased,  and  a  very  loose 
dura  indicates  atrophy  of  the  brain.  The  thickness  of  the  dura 
may  be  measured  approximately  by  inspection ;  if  normal,  the  out- 
lines of  the  convolutions  and  cerebral  vessels  may  be  seen  through 
it.  Examine  the  superior  longitudinal  sinus  before  removing  the 
dura.  To  remove  the  dura,  introduce  the  amputating  knife  just 


Fig.  36. — Removing  the  skull  cap.      The  angular  method  offers  many  advantages  over  the 
original  circular  method. 

to  the  left  of  the  anterior  falx  and  cut  with  a  sawing  motion.  Put 
the  fingers  under  the  dura  and  separate  off  the  vessels;  then  cut 
the  anterior  falx  and  strip  back  the  dura. 

Removing  the  Brain. — Place  the  forefinger  of  the  left  hand  un- 
der the  frontal  lobes  and  pull  upward.  With  a  sharp  scalpel  cut 
each  pair  of  cranial  nerves  near  the  exit  from  the  cranial  cavity. 
Cut  the  internal  carotid  artery  and  the  tentorium  with  the  point 
of  the  knife  sliding  along  on  the  crest  of  the  petrous  bone,  lifting 
up  the  temporal  lobe  on  either  side  as  this  is  done.  Insert  the  knife 


TECHNIC   OF   PRIVATE   POST-MORTEM.  163 

through  the  foramen  magnum,  severing  the  spinal  cord  and  verte- 
bral vessels.  The  brain  is  laid  on  the  table. 

Examination  of  the  Brain. — The  upper  surface  of  the  brain  is 
examined  and  then  turned  over.  Carefully  examine  each  vessel  in 
the  circle  of  Willis.  To  open  the  lateral  ventricles,  strip  away  the 
meninges  from  the  top,  but  leave  those  on  the  sides  in  position  in 
order  to  support  the  brain  substance.  With  fingers  separate  the 
hemispheres  until  the  corpus  callosum  comes  into  view.  Each  of 
the  lateral  ventricles  may  be  opened  by  inserting  the  knife  without 
injuring  the  convolutions.  To  open  the  third  ventricle,  cut  the 
anterior  attachment  of  the  corpus  callosum  and  the  lateral  pedun- 
cles, and  inspect  the  interior.  To  open  the  fourth  ventricle,  make 
a  longitudinal  incision  through  the  vermis.  To  examine  the  cere- 
bellum, make  pig-pen  incisions  into  its  substance.  To  examine 
the  cerebral  substance,  make  two  sweeping  longitudinal  incisions 
of  cortex  and  transverse  cuts  entirely  through  the  pons  (pons 
varolli). 

Examination  of  Special  Sense  Organs. — Post-mortem  examina- 
tions of  the  eye  and  ear  are  rarely  made  save  by  experts.  After 
removing  the  brain,  the  roof  of  the  orbit  or  of  the  middle  and 
internal  ears  may  be  chiseled  off  and  these  regions  examined  from 
above. 

Chief  Incision  of  the  Trunk. — This  extends  from  Adam's  apple 
(pomum  Adami)  to  the  root  of  the  penis  (Fig.  37),  and  is  best 
made  with  a  scalpel  or  cartilage  knife.  The  skin  over  the  neck  is 
loose,  and  must  be  stretched  with  the  fingers  of  the  left  hand  as 
the  incision  proceeds.  On  reaching  the  sternum,  the  belly  rather 
than  the  point  of  the  knife  is  used,  and  the  cut  made  deep  to  the 
bone.  At  the  ensiform  cartilage  the  pressure  must  be  diminished. 
On  reaching  the  epigastrium,  a  cut  is  made  entirely  through  to  the 
peritoneum  and  two  fingers  of  the  left  hand  inserted,  one  on  either 
side  of  the  knife,  the  fingers  closely  following  the  path  of  the  knife, 
keeping  the  tissues  taut.  The  incision  is  passed  around  to  the  left 
of  the  umbilicus,  so  that  the  connections  of  the  latter  with  the  liver 
may  not  be  disturbed.  On  reaching  the  pubis  the  cut  is  made  deep 
to  the  bone. 

Preliminary  Abdominal  Inspection. — At  this  time  a  brief  in- 
spection of  the  abdominal  cavity  may  be  made,  noting  the  appear- 
ance of  the  peritoneum  and  omentum,  amount  and  character  of 
fluid,  position  of  viscera,  distention  of  gut,  and  perforations.  Take 


164 


LABORATORY    METHODS. 


the  height  of  the  diaphragm.  A  transverse  abdominal  incision 
may  be  avoided  by  running  the  knife  under  either  rectus  and  cut- 
ting upward  to  the  skin,  entirely  severing  these  muscles.  If  t\vo 
men  are  at  work,  one  may  continue  the  examination  of  the  a'.i- 


Pig.  37. — Initial  incision.      The  initial  incision  of  the  trunk  extends  from  Adam's  apple 
to  the  root  of  the  penis. 

dominal  contents,  or  otherwise  a  wet  cloth  should  cover  these  until 
the  thoracic  examination  has  been  completed. 

Opening  the  Chest. — At  this  time  examine  the  breast  by  a  cut 
underneath,  which  may  be  easily  hidden.  With  well-directed  cuts 
peel  both  flaps  of  skin  and  muscle  from  the  ribs  as  far  back  as  the 
axilla,  examining  the  glands  of  this  region  and  also  the  sternum 
and  ribs.  Beginning  at  the  second  rib,  cut  each  costal  cartilage 
at  its  junction  with  the  bony  portion  of  the  rib.  Cut  the  dia- 
phragmatic attachments  below,  and  raise  the  lower  end  of  the 


TECHNIC   OF   PRIVATE   POST-MORTEM. 


165 


sternum  with  the  cartilages.  With  the  cartilage  knife  disarticulate 
the  clavicles  and  first  ribs  from  the  sternum.  Forcibly  separate 
the  tissues  of  the  anterior  mediastinum  and  remove  the  piece. 
Avoid  cutting  the  jugulars,  as  bleeding  would  be  very  profuse. 
Examine  the  thymus  and  internal  surface  of  the  sternum. 
Examination  of  the  Heart. — This  is  best  examined  in  position. 


Fig.  38. — Examination  of  the  heart.      The  heart  may  be  examined  in  position.      A,  outlet 
of  left  pulmonary  veins. 

After  noting  the  position  of  the  apex,  remove  a  large  portion  of 
the  anterior  pericardium,  and  you  will  be  ready  to  open  the  left 
heart.  Seize  the  apex  and  swing  over  to  the  right,  holding  tautly 
in  this  position  (Fig.  38),  when  the  left  ventricle  will  become  very 
convex.  Run  the  point  of  the  knife  into  the  apex  of  the  left  ventri- 
cle, and  cut  upward  in  a  line  ending  at  the  posterior  edge  of  the 
junction  of  the  left  pulmonary  vein  and  left  auricle.  The  actual 


166  LABORATORY    METHODS. 

cut,  however,  stops  short  of  the  auriculo- ventricular  septum. 
Measure  and  examine  this  valve,  and  then  open  up  the  left  auricle 
and  pulmonary  veins.  The  valvular  openings  are  usually  meas- 
ured by  inserting  the  fingers.  (See  page  158.)  The  aorta  is  not 
usually  examined  at  this  time.  The  right  heart  may  then  be  opened 
by  permitting  the  organ  to  return'  to  its  natural  position,  and  mak- 
ing a  cut  through  the  anterior  flap,  beginning  at  its  edge,  and,  per- 
pendicular to  the  cut,  extending  it  toward  the  right.  The  cut 
should  pass  through  the  greatest  transverse  convexity,  and  may 
be  continued  several  inches.  Another  cut  extends  upward  from 
this  to  the  auriculo-ventricular  septum,  and,  after  measuring  and 
inspecting  this  valve,  the  auricle  and  pulmonary  artery  are  ex- 
amined. The  aorta  is  measured,  and  then  opened  and  examined. 

Removal  and  Examination  of  the  Lungs. — Adhesions  are  loos- 
ened between  the  visceral  and  parietal  pleura?  if  possible,  as 
otherwise  the  parietal  layer  may  be  stripped  from  the  ribs.  After 
cutting  the  bronchial  and  vascular  attachments,  both  lungs  are  re- 
moved and  laid  on  the  table  for  examination.  After  a  thorough 
inspection  of  the  pleurae,  numerous  incisions  will  expose  the  lung 
substance.  Special  attention  should  be  given  to  the  apices.  Open 
up  the  larger  bronchi  and  vessels. 

Neck  Organs. — These  are  usually  examined  in  position,  and 
rarely  offer  much  in  a  diagnostic  sense.  The  incision  of  the  thyroid 
will  demonstrate  the  presence  of  cysts  or  tumors. 

Examination  of  the  Spleen. — This  is  seized  with  both  hands, 
and  the  phrenosplenic  ligaments  stretched  or  detached.  It  is  laid 
on  the  edge  of  the  ribs,  and  the  principal  incision  made  from  pole 
to  pole.  It  may  thus  be  examined  and  returned  to  its  position  with- 
out cutting  the  gastrosplenic  omentum. 

Removal  and  Examination  of  the  Kidneys  and  Adrenals. — Pull 
over  the  omentum  and  intestines  to  the  right.  Nick  peritoneum 
between  descending  colon  and  spinal  column,  and  then  lay  aside 
the  knife,  completing  with  the  hands  a  peritoneal  dissection  of  the 
left  kidney  and  loosening  it  from  its  anchorage.  Cut  the  vessels 
on  the  bodies  of  the  vertebra?,  but  cut  the  ureter  somewhat  lower 
down.  The  kidney  is  then  removed.  Now  hold  it  in  the  palm  of 
the  hand  in  such  a  manner  that  the  ureter  hangs  between  the  fin- 
gers, and  cut  through  the  opposite  convex  surface  from  pole  to 
pole  and  into  the  pelvis.  Slit  the  ureters.  Attempt  to  strip  the 
capsule,  and  make  other  necessary  observations.  The  right  kidney 


TECHNIC    OP   PRIVATE   POST-MORTEM.  167 

is  removed  in  a  similar  manner,  and  its  adrenal  is  most  likely  to 
be  closely  bound  to  the  liver. 

Removal  and  Examination  of  the  Intestines.— The  duodenum 
need  not  be  removed.  Separate  the  stomach  and  transverse  colon 
with  the  fingers,  and  then  cut  transverse  mesocolon  just  back  of 
transverse  colon,  working  from  below.  Tear  down  the  sigmoid 
mesocolon.  Pass  a  couple  of  ligatures  around  the  gut  at  the  junc- 
tion of  the  sigmoid  and  rectum,  and  sever  it  between  these.  The 
hepatic  flexure  may  be  torn  loose  and  the  ascending  colon  freed 
from  its  attachments  to  the  ileum.  The  small  intestine  is  next 
separated  from  its  mesentery  by  holding  it  taut  and  using  the 
knife  with  a  fiddle-bow  motion.  Pass  two  ligatures  around  the 
junction  of  the  duodenum  and  the  jejunum,  and  divide  the  gut 
between  these.  The  intestines  are  now  floated  in  a  bucket  of  cold 
water,  opened,  washed,  and  examined.  They  may  be  opened  with 
shears  having  one  probe  point,  or  with  a  pair  of  ordinary  shears 
having  one  point  protected  with  a  lead  buckshot. 

Examination  of  the  Duodenum. — This  is  usually  examined  in 
the  body  of  the  cadaver,  being  easily  opened  with  curved  shears, 
carefully  avoiding  the  bile  papilla.  Squeeze  the  gall-bladder  for 
evidences  of  stenosis  of  its  duct;  if  this  is  open,  the  bile  should 
enter  the  duodenum.  A  finger  may  be  inserted  through  the  pyloric 
orifice  to  examine  for  patency. 

Examination  of  the  Stomach. — It  is  rarely  necessary  to  remove 
this  organ  in  order  to  examine  it.  A  ligature  may  be  passed 
around  the  lowest  part  of  the  esophagus  and  the  highest  part  of  the 
duodenum,  and  a  longitudinal  incision  along  the  anterior  wall 
midway  between  the  curvatures  will  expose  all  parts  of  the  mu- 
cosa. 

Examination  of  the  Pancreas. — Do  not  remove  it  from  the  cada- 
ver. This  is  the  hardest  organ  in  the  body,  and  a  few  transverse 
cuts  should  be  sufficient.  A  piece  m#y  be  removed  for  microscop- 
ical study. 

Examination  of  the  Liver. — This  may  be  examined  in  the  body, 
a  long  incision  in  the  anterior  aspect  usually  sufficing  to-  show  all 
macroscopic  morbid  changes. 

Examination  of  Retroperitoneal  Structures. — Glands,  ganglia, 
vessels,  etc.,  may  be  examined  after  removing  the  pancreas  and 
mesentery. 

Removal  and  Examination  of  the  Male   Genitalia. — Separate 


168  LABORATORY    METHODS. 

the  bladder  from  the  anterior  abdominal  wall  with  the  fingers  and 
an  occasional  use  of  the  knife.  Work  the  hand  in  behind  and  under 
the  rectum,  prostate,  and  urethra,  and  cut  off  the  mass,  taking 
care  to  cut  the  rectum  low  and  the  urethra  just  anterior  to  the 
prostate.  These  organs  are  laid  on  the  table,  opened,  and  exam- 
ined. 

Removal  and  Examination  of  the  Female  Genitalia. — Separate 
the  bladder  from  the  pubis  as  in  the  male,  also  dissecting  loose  the 
rectum  from  the  sacrum  with  the  hand.  Separate  the  cadaver's 
legs  and  pass  two  elliptical  cuts  around  the  external  genitalia, 
following  the  pelvic  outlet,  meeting  in  front  at  the  lowest  point  of 
the  chief  incision  of  the  trunk  and  behind  at  the  back  of  the  anus. 
Dissect  upward,  keeping  the  point  of  the  knife  close  to  the  bone. 
The  mass  is  removed  through  the  superior  strait,  laid  on  the  table, 
and  the  various  organs  opened  and  examined. 

Removing  the  Cord. — In  case  the  examinations  of  the  thoracic 
and  abdominal  viscera  (page  164)  are  omitted,  the  cord  may 
be  removed  from  the  dorsum,  as  otherwise  the  ventral  method  is 
preferable. 

Removing  the  Cord  Ventralward. — In  case  this  is  to  be  done, 
remove  all  thoracic  and  abdominal  organs,  and  sponge  the  cavity 
dry.  Beginning  at  the  neck,  remove  all  muscles  and  soft  parts 
from  the  bone.  Place  a  block  under  the  lumbar  region,  and  with 
a  heavy  scalpel  or  cartilage  knife  cut  through  the  last  two  inter- 
vertebral  disks,  using  the  belly  and  not  the  point  of  the  blade,  as 
transverse  processes  protect  the  cord  here.  With  the  bone  forceps 
snap  the  pedicles  of  the  last  lumbar  vertebra  and  remove  the  freed 
body.  Cut  loose  the  other  pedicles  with  a  hammer  and  chisel, 
working  from  below  upward,  cutting  disks  and  removing  bodies  of* 
the  vertebrae  as  loosened.  The  spinal  roots  are  put  on  a  tension 
and  cut  with  scissors,  when  the  cord  is  lifted  out. 

Removing  the  Cord  from  the  Dorsum. — This  method  is  selected 
in  case  the  remainder  of  the  autopsy  is  omitted,  but,  on  account  of 
the  hypcstasis  usually  present,  it  is  by  no  means  a  clean  operation. 
A  median  incision  extends  from  the  hair  line  to  the  sacral  dimple 
and  marks  the  tips  of  the  spinous  processes.  The  skin  flaps  are 
then  dissected  back  on  both  sides.  The  muscle  flaps  are  made  by 
incisions  hugging  the  sides  of  the  spinous  processes  and  dissected 
in  a  similar  manner.  These  may  be  reflected  outward,  and  held  in 
place  by  hooks,  or  may  be  entirely  removed.  The  lamina?  and 


TECHNIC   OF   PRIVATE   POST-MORTEM.  169 

spinous  processes  are  removed  with  a  saw  or  chisel,  or  both,  and  the 
cord  is  released  as  described  above. 

Autopsy  of  the  New  Born. — Several  alterations  in  technic  are 
necessary  when  making  the  necropsy  of  an  infant.  The  scalp  in- 
cision is  identical  with  that  used  in  the  adult,  but  the  bones  may 
be  separated  by  cutting  their  membranous,  connections  with  shears. 
Ligatures  are  passed  around  the  trachea  and  esophagus  before  open- 
ing the  chest.  The  lungs  and  the  heart  should  float  if  the  child 
has  breathed.  If  any  lobe  of  the  lung  floats,  the  infant  has  at  least 
gasped.  The  stomach  is  opened  under  water.  Bubbles  of  gas 
usually  indicate  that  air  has  been  swallowed,  though  they  are 
sometimes  due  to  fermentation. 

Completing  the  Autopsy. — Although  notes  may  be  taken,  it  is 
best  to  defer  the  extended  discussion  of  findings.  Bones  may  be 
wired  back  into  place  and  incisions  carefully  sutured.  Every 
effort  should  be  made  to  restore  the  cadaver  to  its  best  condition, 
which  applies  especially  to  those  parts  which  may  be  seen  at  the 
funeral. 


170 


LABORATORY    METHODS. 


CHAPTER  XV. 


TO  FIND  THE  TREPONEMA  PALLIDUM  IN  SIX  MINUTES. 
Apparatus.  — 


1.  Beaker  or  evaporating  dish. 

2.  Flame. 

.'?.   Higgins'  carbon  suspension. 

4.  Medicine  dropper. 

5.  Microscope  and  accessories. 


6.  Needle. 

7.  Physiologic  salt  solution. 

8.  Scalpel. 

9.  Slides  and  cover  glasses. 
10.  Thermometer. 


Obtaining  the  Specimen. — Tease  lightly  the  surface  of  the  sus- 
pected mucous  patch  or  cutaneous  ulcer,  or  scrape  gently  with  a 
sharp  scalpel  the  papule  or  chancre.  If  the  surface  of  the  sus- 
pected syphilelcus  seems  moist  or  gummy,  this  first  step  may  be 
omitted.  The  fluid,  a  warm  physiologic  salt  solution,  is  quickly 
dropped  from  the  capillary  pipette  on  this  surface  and  as  quickly 
withdrawn  (Fig.  40).  An  ordinary  medicine  dropper  may  be 
drawn  out  in  the  flame  to  serve  as  a  pipette.  Four  droplets,  or 
less,  of  the  solution  usually  suffice,  as  the  suspension  of  the  trepo- 
nemaa  will  be  more  concentrated  than  where  larger  amounts  of  the 
liquid  are  used.  As  the  solution  cools  very  quickly,  there  should 
be  no  delay.  For  practical  purposes,  a  physiologic  salt  solution 
may  be  prepared  by  adding  1  teaspoonful  of  pure  sodium  chlorid 
to  1  quart  of  distilled  water,  which  should  be  kept  warm,  but  not 
hot. 

Preparing  the  Specimen. — A  clean  slide,  on  which  lias  been 
placed  a  droplet — not  a  drop — of  Higgins'  waterproof  black  draw- 
ing ink,  is  ready  to  receive  1  or  2  droplets  of  the  suspension  as 
prepared  above.  After  the  ink  and  droplets  are  thoroughly  mixed 
with  a  needle  or  platinum  wire,  tbe  preparation  is  ready  for  ex- 
amination. A  cover  glass  may  be  added  at  once  and  the  specimen 


References. — Burri :  Wiener  Klinische  Wochenschrift,  July  1,  1909:  Williams: 
Archives  of  Diagnosis,  January,  1910,  and  Journal  of  American  Medical  Association, 
December  10,  1910;  Barach :  Journal  of  American  Medical  Association,  November  26, 
1910. 

171 


172 


LABORATORY   METHODS. 


examined  wet.  This  is  not,  however,  the  method  preferred  in  all 
cases  by  the  authors,  and,  although  desiccation  often,  but  not  in- 
variably, causes  a  loss  of  characteristic  windings,  a  dried  prepara- 
tion is  more  likely  to  show  a  typical  ideal  field.  If  a  dry  examina- 


Fig.  40. — Making  the  suspension. 


tion  is  desired,  no  cover  glass  is  to  be  applied  until  all  evidences 
of  moisture  are  lost.  A  slight  spreading  of  the  droplet  is  advis- 
able, but  this  should  not  be  overdone,  as  otherwise  the  ideal  fields 
will  be  difficult  to  find  (Fig.  41).  When  the  preparation  has  dried, 


TO   FIND   THE   TREPONEMA   PALLIDUM.  173 

it  will  show  a  black  center  and  a  small  brown  peripheral  margin. 
The  former  represents  carbon  deposits,  and  the  latter  consists 
mainly  of  dried  fluid,  which  contains  a  very  concentrated  collection 


A  B 

Fig.  41. — Spreading  the  mixture.  A,  correct  spread,  lighter  areas  showing  usual  loca- 
tions of  ideal  fields,  the  bulk  of  the  carbon  remaining  in  the  center  as  the  drying 
proceeds;  B,  droplet  spread  too  thoroughly,  with  no  concentration  of  the  treponemw. 

of  the  treponemae.  That  portion  of  the  field  last  to  dry  contains 
the  most  of  these  germs. 

Examination  in  the  Wet. — By  this  method  the  examination  may 
be  done  at  once.  The  treponemas  may  be  observed  in  motion,  and 
the  characteristic  windings  or  turns  of  the  germs  are  not  lost.  The 
examination  is  done  in  a  strongly  transmitted  light,  and  large 
masses  of  carbon  are  to  be  avoided  when  searching  the  field.  The 
pearly  white,  almost  transparent,  treponemae  are  easily  recognized 
on  a  homogeneous  brown  or  black  background,  and  appear  highly 
magnified  as  a  result  of  this  differentiation. 

Examination  in  the  Dry. — "When  all  evidences  of  moisture  have 
disappeared,  add  a  drop  of  balsam  and  a  clean  cover  glass.  Search 
for  an  ideal  field ;  i.  e.,  that  area  which  contains  the  least  carbon 
and  the  most  organic  matter— not  only  treponemae,  but  leukocytes, 
bacilli,  etc.  This  area  is  usually  located  at  the  periphery  if  the 
spreading  has  not  been  overdone.  The  specific  microorganism 
appears  much  the  same  as  in  the  wet  preparations,  except  that  no 
motions  are  observed,  and  the  characteristic  windings  are  some- 
times, though  not  invariably,  lost. 

Identification  of  the  Treponema  Pallidum. — In  order  to  make  a 
positive  diagnosis,  both  wet  and  dry  specimens  should  be  exam- 
ined. The  treponema  pallidum  may  be  distinguished  from  spiro- 
chetse,  spirilla,  cracks,  extraneous  fibers,  etc.,  by  the  following  gen- 


174  LABORATORY   METHODS. 

eral  characteristics:  a  motile  corkscrew,  much  more  delicate  than 
the  other  forms;  these  turns  are  close  and  regular,  and  appear  to 
be  somewhat  flexible ;  its  geometric  regularity  in  the  spirals,  which 
are  deeply  cut.  A  thorough  study  of  this  microorganism  may  be 
made  either  from  the  literature  or  from  control  specimens  before 
making  a  decision. 

The  scientific  world  relies  almost  entirely  on  the  morphological 
characteristics  to  identify  the  treponema,  no  practical  cultural 
methods  being  known.  If  any  germ  or  element  is  found  to  be 
identical  in  form  and  motion  with  Schaudinn's  specific  microor- 
ganism, we  are  then  ready  to  cast  aside  as  useless  not  only  the  ink 
methods,  but  the  dark  field  differentiation  method  on  which  the 
expert  relies.  Nor  can  the  staining  time  and  characteristics  be 
termed  constants,  for  in  case  the  treponema  pallidum  is  actually 
found  in  these  inks — and  it  never  has  been — the  drawing  inks  may 
then  be  abolished  along  with  the  public  drinking  cup.  (See  criti- 
cism of  the  method  below.) 

Sources  of  Error.— 

1.  Use  no  disinfectant  on  the  syphilelcus  for  several  hours  be- 
fore obtaining  the  specimen.     Inquire  about  the  recent  use  of  mer- 
cury or  606,  as  the  authors  have  noted  that  either  may  cause  the 
rapid  disappearance  of  the  treponemae  from  the  lesion. 

2.  Keep  the  salt  solution  warm,  but  not  hot. 

3.  Use  droplets,  not  drops. 

4.  Do  not  overdo  the  spreading. 

5.  Find  an  ideal  field  before  attempting  to  identify  the  trepo- 
nemae. 

6.  Study  well  the  characteristics  of  this  germ  before  reaching 
a  decision. 

Disadvantages  of  the  Method.— 

1.  Every  field  is  not  ideal;1 

2.  Inks  are  not  sterile,  and  may  contain  many  microorganisms. 
No  report  has,  however,  been  made  that  any  observer  has  identi- 
fied the  treponema  in  these  inks. 

Criticism  of  the  Method. — The  following  criticism  has  been 
made  of  this  method:  Certain  wavy  fibers  and  cracks  appear  in 
these  inks  (Fig.  42),  and,  while  most  of  them  would  not  receive 


1  To  those  who  prefer  to  use   the  India   ink   as  suggested  by  Bnrri,    the    "Chin-Chin 
Liquid  Pearl,"   distributed  by  Bausch  &  Lomb  Optical  Company,   is  recommended. 


TO   FIND   THE   TREPONEMA   PALLIDUM.  175 

very  serious   consideration  by  the   experienced  microscopist,   the 
general  practitioner  is  warned  against  their  use. 

Alas,  the  general  practitioner !  Although  he  has  graduated  from 
our  best  medical  schools,  and  usually  during  the  era  of  microscopy, 
he  is  hardly  given  the  credit  of  being  able  to  distinguish  a  urinary 
cast  from  a  cotton  fiber.  No  critic,  however,  has  yet  said,  "After 
a  careful  investigation  I  can  not  distinguish  fibers  and  cracks  from 
microorganisms."  When  competent  observers  can  make  this  state- 
ment, then  shall  we  be  prepared  to  lay  aside  as  worthless  not  only 
the  simple  methods,  but  practically  everything  that  we  have  thus 
far  learned  about  Schaudinn's  specific  germ.  The  treponema  has 
not  as  yet,  however,  filled  all  the  requirements  of  Koch's  law. 


ABC  D  E  F 

Fig.  42. — Treponema  pallidum.      A,  treponema  pallidurii ;  B,  spirocheta  refringens;  0,  a 
spirillum;  D,  cotton  fibers;  E,  flaxen  fibers;  F,  cracks  in  ink. 

Advantages  of  the  Method. — It  is  simple,  rapid,  and  the  sus- 
pension of  the  treponeiruc  is  twice  concentrated,  giving  in  the  ideal 
field  a  maximum  number  of  germs.  For  the  office  or  bedside 
diagnosis  of  syphilis  the  practitioner  who  has  mastered  his  labora- 
tory courses,  and  who  has  kept  informed  on  the  trej>onema  pal- 
lidum, may,  with  a  little  additional  study  and  practice,  depend  on 
the  method  given  in  this  chapter. 

Principle  Involved  in  the  Technics.— 

1.  There  are  many  treponemae  on  the  surface  of  every  syphilel- 
cus. 

2.  These   treponemje   show   a   preference   for  liquids,   having  a 
tendency  to  leave  their  host  with  the  drawing  off  of  certain  solu- 
tions properly  applied. 


176  LABORATORY    METHODS. 

3.  Higgins'  ink,  being  a  suspension  of  carbon  in  a  dark  fluid, 
permits,  when  drying,  the  formation  of  the  ideal  field,  which  con- 
tains most  of  the  treponemaa  and  but  little  carbon. 

4.  The  treponemae  are  not  stained  by  this  ink,  but  appear  as 
pearly,  almost  transparent,  bodies  on  a  homogeneous  brown  or  black 
background,  and  appear  magnified  as  a  result  of  this  differentia- 
tion. 


CHAPTER  XVI. 

LABORATORY  PROPHYLAXIS. 

The  Safe  Operator. — The  practice  of  medicine — no  less  its  work- 
shop— is  no  place  for  the  diffident  practitioner.  The  days  of 
"miasms"  have  long  passed,  and  we  know  too  much  concerning 
the  subject  of  bacteriology  to  hesitate  to  seek  a  bit  further  when 
opportunity  offers.  We  should  not,  however,  despise  the  "insig- 
nificant little  germs."  The  competent  bacteriologist  has  usually 
passed  through  at  least  three  stages  in  his  development.  In  the 
first  stage  he  enters  the  field  trembling  with  fear,  and  expects 
disaster  from  many  sources.  He  is  therefore  overcautious,  and 
consequently  nothing  goes  amiss.  After  a  time,  in  the  second 
stage,  he  wearies  of  "details,"  his  fear  of  microorganisms  grows 
less  and  less,  and  he  often  explains  his  carelessness  by  "vital  re- 
sistance." His  evolution  to  the  third  stage  may  be  delayed  for 
years,  but  usually  takes  place  when  he  least  expects  it.  There 
comes  a  day  of  awakening,  which  may  end  his  bacteriological 
career,  but  which  usually  ushers  in  the  second  reign  of  caution, 
and  he  is  now  qualified  to  become  an  expert  in  this  field — in  other 
words,  he  has  become  a  safe  operator. 

Germicides,  Antiseptics,  and  Disinfectants. — A  germicide  is  an 
agent  which  kills  germs,  an  antiseptic  prevents  or  inhibits  their 
development,  while  a  disinfectant  may  do  either  or  both.  A  brief 
study  of  the  subject  will  show  that  distinctions  are  not  sharply 
drawn,  but  on  one  point  there  seems  to  be  a  general  agreement 
among  all  authorities — i.  e.,  most  chemical  disinfectants  which 
may  safely  come  into  direct  contact  with  the  epidermis  of  the  liv- 
ing man  are  likely  to  possess  very  weak  germicidal  properties. 
Chemical  antiseptics  are  of  service  only  when  present,  but,  when 
removed,  those  germs  remaining  are — so  far  as  strictly  antiseptic 
action  has  been  realized — freed  from  any  restraining  influences. 

Bacteriophobia  Versus  Carelessness. — The  man  who  is  "germ 
afraid ' '  should  be  debarred  from  the  practice  of  medicine  and  from 
the  clinical  laboratory.  On  the  other  hand,  the  careless  diagnos- 

177 


178  LABORATORY    METHODS. 

tician  is  most  likely  to  be  a  careless  therapeutist,  and  is  by  no 
means  a  safe  worker  for  either  department. 

Certain  precautions  were  presented  in  Searching  for  Germs,  page 
42.  These  admonitions  were  selected  not  only  from  standard 
works,  but  from  actual  experiences  in  the  authors'  laboratories, 
and  are  based  on  the  knowledge  concerning  germs  and  their  habits 
and  life  processes.  The  operator  may  carry  in  his  mind  a  picture 
of  what  he  is  actually  doing,  and  endeavor  to  explain  each  step,  as 
follows : 

1.  He  heats  to  incandescence  the  platinum  loop,  thereby  destroy- 
ing all  germs  which  may  be  contaminating  it. 

2.  He  permits  it  to  cool,  so  that  it  may  not  quickly  destroy  the 
inoculation. 

3.  He  keeps  his  hand  off  it,  and  does  not  allow  it  to  touch  any- 
thing, so  that  recontamination  may  not  occur. 

4.  He  knows  that,  if  it  is  held  in  the  air,  germs,  may  quickly 
alight  on  it,  and  he  therefore  proceeds  quickly  with  his  techuic. 

5.  He  touches  the  point  of  the  wire  to  the  moist  colcny,  and 
knows  that  some  of  the  many  thousands  of  germs  present  must 
adhere. 

6.  He   removes   the   wire   with   the   captured    germs,    studiously 
avoiding  contamination,  and  proceeds  to  inoculate  the  second  tube. 

If  he  is  timid  or  careless,  his  technic  falls  short  at  some  point. 
and  his  inoculation  either  fails  or,  unfortunately,  is  not  made  in 
the  second  tube. 

Special  Bacteriological  Cautions. — General  precautions  in  re- 
gard to  sterilization  and  safe  technic  will  be  found  in  Searching 
for  Germs,  page  39.  When  working  in  the  bacteriological  labora- 
tory all  wounds  on  the  hands  should  be  protected  with  bichlorid 
of  mercury  dressings,  or  work  should  be  discontinued  until  an 
aseptic  healing  occurs.  When  working  with  diphtheritic  material 
the  body  orifices,  including  the  eyes,  must  be  studiously  avoided 
with  the  fingers,  and  the  hands  should  be  thoroughly  scrubbed  and 
rinsed  after  the  examinations  are  completed.  A  gargle  of  an  anti- 
septic nature  should  be  used  while  working  with  the  culture  and  for 
several  days  afterward.  When  much  of  this  work  is  done,  a  gargle 
of  this  character  should  be  kept  in  the  washroom.  Special  cart-  of 
the  eyes  should  be  taken  when  working  with  all  genital  secretions, 
as  a  single  gonococcus  in  a  case  of  old  gleet  or  leucorHica  may 
cause  an  acute  and  destructive  ophthalmia.  After  searching  for 


LABORATORY   PROPHYLAXIS.  179 

the  treponema  pallidum  the  hands  should  be  soaked  in  a  1 : 1,000 
solution  of  bichlorid  of  mercury — perhaps  the  only  instance  where 
this  chemical  acts  as  a  germicide.  Netting  over  the  window  as  a 
precaution  against  the  housefly  and  general  cleanliness  will  make 
the  bacteriological  workshop  many  times  safer  than  an  indifferent 
use  of  chemicals — those  false  securities  in  mysterious  blue  solution 
which  rarely  kill  germs.  Plenty  of  light  should  fall  on  the  labo- 
ratory table.  Do  not  smoke  or  eat  in  a  bacteriological  laboratory. 

Autopsy  Prophylaxis. — The  routine  use  of  gowns,  rubber  gloves, 
and  general  bacteriological  measures  is,  of  course,  recommended. 
The  cold  water  used  during  the  post-mortem  may  contain  bichlorid 
of  mercury,  but  from  this  alone  safety  can  not  be  expected. 

Not  only  are  the  acute  infections — as  diphtheria  and  typhoid — 
dangerous,  but,  strangely  enough,  tuberculosis  and  actinomycosis 
seem  especially  prone  to  attack  the  prosector. 

Wounds  from  bone  splinters  are  invariably  fatal  unless  properly 
treated.  The  vitality  of  germs  powerful  enough  to  survive  the 
bactericidal  action  of  the  bone  would  indicate  also  their  great  viru- 
lence when  coming  in  contact  with  living  tissues  of  a  weaker  class. 
Cases  of  malignant  endocarditis  are  especially  dangerous,  and  the 
necropsy  of  such  cases  should  be  attended  with  great  care. 

Skin  tubercles,  or  the  verrucas  necrogenicaj,  are  common,  but  are 
not  to  be  underestimated,  as  they  have  a  tendency  to  spread, 
coalesce,  and  ulcerate.  They  should  always  be  cauterized. 

Any  wound  occurring  during  a  necropsy  should  be  made  to 
bleed  freely  and  then  cauterized.  Bichlorid  of  mercury  dressings 
should  be  used,  and  these  should  be  changed  at  intervals.  No 
wound,  and  especially  a  deep  one,  should  be  covered  with  adhesive 
plaster  or  celloidin,  as  conditions  would  then  become  ideal  for  the 
tetanus  bacillus  to  flourish. 

Burns  by  Fire. — Burns  by  boiling  water,  heated  apparatus,  or 
even  the  free  flame,  are  not  uncommon  in  laboratory  work.  A  test 
tube  of  water  which  is  being  heated  should  always  be  pointed  away 
from  the  operator,  and  should  be  continually  shaken  to  avoid 
"shooting." 

Burns  of  the  first  degree  should  be  quickly  covered  with  starch 
paste  or  soda  water,  and  afterward  smeared  with  petrolatum  and 
wrapped  with  cotton  or  bandages.  If  as  much  as  one-quarter  of 
the  body  is  affected,  the  patient  should  be  put  to  bed  immediately, 
and  strychnin  as  well  as  morphin  administered  according  to  indica- 


180  LABORATORY    METHODS. 

tions.  Such  a  burn  is  often  followed  by  a  shock  or  nervous  chill, 
and  plenty  of  bed  clothes  should  be  at  hand.  For  the  treatment 
of  shock,  reference  may  be  made  to  standard  surgical  text  honk*. 
Some  fever  usually  follows  a  severe  burn,  for  "which  the  treatment 
should  be  according  to  accepted  practice. 

Burns  of  the  second  degree  should  receive  treatment  similar  to 
burns  of  the  first  degree.  The  blebs  may  be  punctured  with  a 
hypodermic  needle,  and  the  serum  aspirated  or  permitted  to  ooze. 
The  detached  epidermis  should  not,  however,  be  removed  at  once, 
but  only  when  it  shows  signs  of  putrefaction,  as  it  forms  a  natural 
skin  graft  and  supplies  epithelial  cells  to  the  new  skin. 

Burns  of  more  severe  type  are  treated  by  cloths  wrung  out  in 
sweet  oil,  petrogen,  or  other  bland  oil. 

Burns  by  Chemicals. — Mineral  acid  burns  should  be  washed  im- 
mediately with  water,  which  will  dilute  and  remove  the  acids,  which 
may  also  be  neutralized  if  soapsuds  are  applied. 

Carbolic  acid  is  not  easily  removed  with  water,  but  alcohol  in 
any  of  its  preparations  may  be  quickly  applied,  removed,  and  again 
applied,  as  it  dissolves,  but  does  not  neutralize,  the  poison.  After 
a  thorough  washing  with  alcohol,  a  piece  of  gauze  soaked  in  alco- 
hol may  be  applied  three  or  four  times  at  intervals  of  half  an  hour, 
after  which  the  burn  may  be  treated  as  if  fire,  rather  than  the 
acid,  were  the  destructive  agent. 

Burns  with  alkalies  are  neutralized  with  vinegar  or  other  dilute 
mineral  acids,  and  treated  as  if  they  were  caused  by  fire. 

Other  caustics,  as  capsicum,  may  be  removed  with  applications 
of  alcohol. 

Explosive  Mixtures. — Considerable  attention  is  given  to  ex- 
plosive mixtures  in  the  discussion  of  the  properties  of  the  various 
reagents  (page  186),  but  it  may  be  well  to  emphasize  here  some 
of  the  more  dangerous  mixtures  of  chemicals: 

1.  Sulphuric  acid  with  water  or  anything  containing  water  in 
considerable  quantity.     Water  should  never  be  added  to  this  acid. 
When  its  dilution  is  necessary,  add  the  acid  carefully  drop  by  drop 
to  the  required  amount  of  water. 

2.  Potassium  chlorate,  potassium  chromate,  and  potassium  per- 
manganate must  not  be  rubbed  up  with  glycerin,  sulphur,  tannic 
acid,  or  other  oxidizable  substances. 

3.  A  sudden  mixing  of  strong  alcoholic  solution  with  nitric  acid 
may  cause  a  quick  and  severe  explosion. 


LABORATORY   PROPHYLAXIS.  181 

4.  Acids  must  be  added  slowly  to  metals  and  carbonates. 

5.  Hydrogen  forms  an  explosive  mixture  with  phosphorus  and 
with  air. 

6.  Phosphorus   should  not  be   permitted  to   remain  in   contact 
with  the  air,  but  must  remain  under  water. 

7.  Sodium  and  potassium  must  be  submerged  in  oil,  free  from 
moisture  and  the  air. 

Inflammable  and  Explosive  Chemicals. — Gases — hydrogen,  car- 
'bon  monoxid.  Volatile  liquids — ether,  rhigolene,  ethyl  chlorid, 
celloidin  solutions.  Nonvolatile  liquids — fixed  oils  and  unguents. 
Solids — phosphorus,  urotropin. 

Substances  Which  Should  Never  be  Inhaled. — These  include 
the  halogens — i.  e.,  chlorin,  bromin,  etc. 

Arsin  must  not  be  inhaled,  even  in  very  small  quantities,  and 
this  precaution  applies  no  less  to  those  gases  given  off  when  any 
preparation  of  arsenic  is  burned.  Garlic-like  fumes  are  given  off 
by  white  arsenic  when  thrown  on  red-hot  coals. 

Hydrocyanic  acid  is  poisonous  when  inhaled  in  any  quantity, 
even  though  very  dilute,  and  as  the  concentration  is  increased  there 
is  likewise  an  increase  in  the  toxicity,  so  that  the  concentrated 
fumes  would  instantly  kill  any  person  exposed. 

The  fumes  of  the  strong  mineral  acids  are  irritating,  and  should 
be  avoided. 

Hydrogen  sulphid  and  carbon  monoxid  gases  are  poisonous,  even 
in  moderate  quantities. 

If  chloroform  is  used  in  a  room  lighted  by  a  free  flame,  a  certain 
amount  of  chlorin  gas  is  formed,  which  acts  as  a  corrosive  on  the 
respiratory  passages. 

Sulphuric  dioxid  and  certain  of  the  oxides  of  nitrogen  and  car- 
bon dioxid  in  sufficient  quantity  are  poisonous. 


CHAPTER  XVII. 


INDICATIONS  FOR  LABORATORY  AIDS. 

1  'In  which  cases  shall  I  resort  to  the  microscope  and  the  test 
tube?"  is  a  question  which  often  arises  in  the  mind  of  the  physi- 
cian. It  is  not  the  aim  of  this  work  to  contrast  the  value  of  the 
clinical  analysis  with  other  forms  of  diagnostics,  as  all  these  pro- 
cedures are  very  important  branches  of  scientific  medicine  and  can 
not  be  properly  separated.  Either  overestimating  or  underesti- 
mating laboratory  aids  is  the  result  of  ignorance  or  confusion,  but 
it  is  safe  to  predict  that  within  the  next  few  years  this  subject  will 
be  viewed  by  the  practitioner  in  a  much  different  light  from  that 
of  the  past. 

Below  is  a  list  of  diseases  in  which  the  "mays"  and  "musts"  of 
laboratory  aids  are  indicated,  the  black  type  indicating  those  cases 
where  expert  assistance  is  considered  necessary. 


INTERNAL  PSOROSPERMIASIS — Exami- 
nation of  excretions  for  coccidia. 

AMEBIC  DYSENTERY — Examination  of 
stools  for  amebae. 

TRYPANOSOMIASIS — This  and  all  other 
diseases  not  found  in  the  temperate 
region  have  been  omitted. 

MALARIA — Blood  smears  are  treated 
with  Wright's  blood  stain  and  a 
search  made  for  the  plasmodium. 

DISTOMIASIS — Examination  of  excreta 
for  flukes. 

TENIA — Examination  of  stools  for 
segments  or  ova. 

ASCARIS  LUMBRICOIDES — Examination 
of  stools  for  adult  worms,  search- 
ing of  muscle  bits  for  encapsulated 
larvae,  and  inspection  of  blood 
smears  for  eosinophilia. 

AXKYLOSTOMIASIS — Examination  of 
stools  for  the  characteristic  seg- 
mented eggs,  tests  for  occult  blood, 


and  studies  of  blood  smears  for 
evidences  of  eosinophilia. 

INTERNAL  MYIASIS — Examination  of 
excretions  or  exudations  for  mag- 
gots. 

TYPHOID  FEVER — Ehrlich's  diazo  re- 
action; blood  smears  for  the  study 
of  white  cells;  simplified  macro- 
scopic agglutination  test  with  dead 
cultures ;  Russo's  methylene  blue 
test;  cultures  for  typhoid  bacilli 
from  rose  spots,  urine,  saliva,  and 
stools;  true  macroscopic  and  mi- 
croscopic Widal  tests  with  living 
typhoid  germs. 

SMALLPOX. 

VACCINIA. 

VARICELLA. 

SCARLET  FEVER — Repeated  urine  ex- 
aminations as  a  prognostic  meas- 
ure. 

MKASLES. 


INDICATIONS   FOR   LABORATORY   AIDS. 


183 


RUBELLA. 

MUMPS. 

^"HOOPING-COUGH. 

INFLUENZA — Search  for  specific  mi- 
crob'rganism. 

DENGUE. 

CEREBROSPINAL  FEVER — Lumbar  punc- 
ture and  examination  of  fluid  for 
causative  germ. 

LOBAR  PNEUMONIA — A  routine  exami- 
nation of  the  sputum  is  interesting, 
but  rarely  conducted  as  a  practical 
measure,  unless  there  is  reason  to 
suspect  a  tuberculous  infection  in- 
stead of  or  in  addition  to  the  rav- 
ages of  the  pneumococcus. 

DIPHTHERIA — Searches  for  the  Klebs- 
L<'5 filer  bacillus. 

ERYSIPELAS — Searches  for  strepto- 
cocci. 

SEPTICEMIA — Blood  smears  may  throw 
some  light  on  the  diagnosis,  espe- 
cially if  there  is  a  question  in  the 
mind  of  the  therapeutist  whether 
to  use  a  streptococcus  or  staphylo- 
coccus  serum. 

SAPRKMIA — The  germs  are  usually  lo- 
cated at  the  initial  focus,  and  are 
rarely  present  in  the  blood;  they 
are  saprogenic  in  character,  and 
the  culture  is  usually  mixed;  it  is 
hardly  worth  while  for  the  prac- 
titioner to  attempt  to  isolate  and 
study  these,  especially  as  it  would 
shed  but  little  light  on  the  thera- 
peutic side  of  the  question. 

RIIKIMATIC  FEVER — Searches  for  the 
various  streptococci;  when  giving 
the  salicylates  in  heroic  doses,  occa- 
sional examinations  of  the  urine 
should  be  made  for  the  presence  of 
casts  and  other  evidences  of  poison- 
ing. 

YELLOW  FEVER. 

HYDROPHOBIA — Examination  of  the 
nervous  system  of  the  dog  for  the 
Negri  bodies. 

TETANUS — A   search    for    the    specific 


organism  may  be  made  along  with 
therapeutic  measures,  but  the  lat- 
ter must  never  be  delayed  for  an 
absolute  diagnosis. 

ACTINOMYCOSIS — Examination  of  pus 
for  specific  microorganisms. 

SYPHILIS — Searches  for  the  trepo- 
nemffi;  the  various  serum  reac- 
tions; cytological  examination  of 
the  cerebrospinal  fluid  in  suspected 
syphilitic  meningitis. 

GONORRHEA — Searches  for  the  specific 
coccus. 

TUBERCULOSIS — Searches  for  Koch's 
specific  bacillus  and  for  the  evi- 
dences of  its  presence — viz.,  elastic 
tissue,  lymphocytes,  etc.,  according 
to  which  portion  of  the  body  is  af- 
fected; section  of  suspicious  lymph 
glands  and  a  study  of  the  patho- 
logical histology;  do  not  attempt  to 
demonstrate  the  presence  of  the 
specific  bacillus  in  tissues,  but  try 
to  prove  the  presence  of  tubercle 
formation. 

ALCOHOLISM,  MORPHINE  HABIT,  MIN- 
ERAL POISONS,  ETC. — Examinations 
of  foods,  drugs,  beverages,  excre- 
tions, etc.;  isolation  of  these  poi- 
sons in  a  pure  form. 

FOOD  POISONING — Examinatio'n  of 
food  samples;  by  "food  poisoning" 
is  commonly  meant  those  disturb- 
ances of  the  vital  processes  arising 
from  the  ingestion  of  foods  in  which 
the  poisons  or  the  decomposition 
products  of  certain  bacteria  are 
present,  which  field  must  be  re- 
served for  the  expert. 

SUNSTROKE. 

ARTHRITIS  DEFORMANS. 

CHRONIC  RHEUMATISM — If  possible,  a 
complete  examination  of  every  por- 
tion of  the  body  should  be  made, 
especially  of  the  tonsils,  pleural 
cavities,  and  other  possible  sources 
of  pus;  such  analyses  may  be  made 
as  are  indicated  by  the  findings. 


184 


LABORATORY    METHODS. 


MUSCULAR  RHEUMATISM. 

GOUT — Examinations  of  the  urine. 

DIABETES  MELLITUS — Examination  of 

the  urine  for  amount,  specific  grav- 

'  ity,    general     appearance,    glucose, 

and  diacetic  acid;   a  search  of  the 

stools  for  intestinal  parasites. 

DIABETES  INSIPIDUS — Examination  of 
the  urine  for  amount  and  specific 
gravity. 

RICKETS — Inquiry  into  the  infant's 
food;  if  necessary,  an  analysis  of 
the  mother's  milk  or  cow's  milk, 
and  modification  accordingly. 

OBESITY. 

STOMATITIS — Search  for  the  thrush 
fungus,  treponema,  etc.,  as  may  be 
indicated;  attempt  the  detection  of 
mercury  if  such  seems  to  be  the 
cause;  determination  of  reaction  of 
saliva. 

DISEASES  OF  THE  SALIVARY  GLANDS. 

DISEASES  OF  THE  PHARYNX — Ulcers 
may  be  examined  for  pathogenic 
bacteria,  especially  the  tubercle 
bacillus,  treponema,  fusiform  bacil- 
lus, and  spirocheta  of  Vincent's  an- 
gina; the  diphtheria  bacillus  and 
pneumococcus  may  be  found  in 
healthy  mouths,  and,  unless  they 
are  present  in  large  numbers,  have 
little  significance. 

TONSILS — Same  as  pharynx;  the  yel- 
low plug  of  acute  tonsilitis  is  really 
a  colony  of  germs,  and  may  show 
thousands  of  streptococci  or  staphy- 
lococci  in  almost  pure  culture. 

DISEASES  OF  THE  STOMACH — Unless 
the  diagnosis  is  evident,  it  is  well 
to  supplement  it  with  an  examina- 
tion of  the  stomach  contents;  add 
to  this  a  test  for  occult  blood 
should  the  presence  of  ulcer  or  can- 
cer be  suspected. 

DISEASES  OF  THE  INTESTINE — Proper 
examination  of  stools,  with  limita- 
tions in  regard  to  interpreting  find- 
ings. 


APPENDICITIS — A  study  of  the  white 
cells,  when  properly  made,  gives 
valuable  diagnostic  and  prognostic 
data. 

INTESTINAL  OBSTRUCTION — Examina- 
tion of  vomited  material  for  evi- 
dences of  biliary  and  fecal  contam- 
ination; macroscopic  inspection  is 
often  sufficient;  indicanuria  is  said 
to  be  present. 

J A r. \DICE — Examination  of  the  urine 
for  biliary  pigments ;  inspection  of 
stools. 

DISEASES  OF  THE  PANCREAS — A  Cam- 
midge  test  may  be  made,  but  at  the 
present  time  the  inferences  drawn 
from  a  positive  reaction  are  sub- 
ject to  dispute;  tests  for  urinary 
glucose. 

PERITONITIS — In  the  chronic  forms 
where  ascites  is  present  an  exami- 
nation of  the  fluid  may  be  made. 

ACUTE  CORYZA. 

HAY  FEVER. 

EPISTAXIS. 

DISEASES  OF  THE  LARYNX — The  symp- 
toms and  signs  of  syphilitic  and 
tuberculous  laryngitis  are  pathog- 
nomonic,  and  the  collection  of  ma- 
terial for  microscopic  examination 
is  often  attended  with  difficulty. 

DISEASES  OF  THE  EAR — A  pus  may  be 
planted  on  nutrient  agar;  a  strepto- 
coccus or  pneumococcus  infection 
is  less  likely  to  show  a  thick  and 
creamy  pus  in  large  amounts  than 
where  the  staphylococcus  is  the 
etiological  agent. 

BRONCHITIS,  BRONCHIECTASIS,  ASTH- 
MA— Sputum  examination. 

DISEASES  OF  THE  LUNGS — Sputum  ex- 
amination. 

DISEASES  OF  THE  PLEURA — Examina- 
tion of  puncture  fluids. 

DISEASES  OF  THE  KIDNEY,  BLADDER, 
ETC. — Examination  of  the  urine. 

DISEASES  OF  THE  BLOOD — Partial  and 
complete  examinations  of  the  blood 


INDICATIONS   FOR    LABORATORY   AIDS. 


185 


for  diagnostic  and  prognostic  data; 
in  case  of  pernicious  anemia  en- 
deavor to  discover  a  cause,  for 
which  examinations  of  the  urine 
and  feces  should  be  made;  in  case 
of  affection  of  the  gastro-intestinal 
tract  endeavor  to  locate  the  cause 
of  chlorosis;  in  the  various  forms 
of  leukemia,  section  and  examina- 
tion of  the  lymph  glands  give  but 
little  diagnostic  data,  but  where 
leukemia  may  be  ruled  out  a  study 
of  these  glands  may  aid  to  differen- 
tiate tuberculosis  from  pseudoleu- 
kemia. 

STATUS  LYMPHATICUS. 

ADDISON'S  DISEASE. 

DISEASES  OF  THE  SPLEEN. 

DISEASES  OF  THE  THYROID. 

DISEASES  OF  THE  THYMUS. 

DISEASES  OF  THE  EYE — In  affections 
of  the  conjunctiva,  associated  with 
exudation,  smears  may  be  made  of 
the  serum  or  pus,  and  these  may 
be  fixed,  stained,  and  studied  for 
the  etiological  element — viz.,  tuber- 
cle bacillus,  gonococcus,  pneumococ- 
cus,  Koch-Weeks  bacillus,  Morax- 
Axenfeld  diplobacillus,  streptococ- 
cus, diphtheria  bacillus,  etc. 

DISEASES  OF  THE  PERICARDIUM — Con- 
siderable experience  is  necessary 
when  attempting  a  puncture;  the 
study  of  the  fluid  obtained  may 
throw  some  light  on  the  disease. 


ORGANIC  DISEASES  OF  THE  HEART — 
The  sputum  may  be  watched  for 
erythrocytes  and  heart  failure  cells; 
the  urine  may  be  examined  for 
casts  and  albumin. 

DISEASES  OF  THE  ARTERIES — Urin- 
alyses. 

NEOPLASMS — Section  and  microscopic 
examination  when  bits  of  suspected 
tissue  can  be  obtained;  when  a  hid- 
den tumor  is  suspected,  examine 
the  blood  for  evidences  of  sarcoma 
(hemoglobinemia)  or  carcinoma 
( cachectic  anemia ) . 

PARASITIC  SKIN  DISEASES — Scrapings 
from  lesions  and  examinations  for 
parasites;  study  of  the  blood  smear 
for  eosinophilia. 

DISEASES  OF  THE  ALIMENTARY  TRACT 
OF  INFANT — Analyses  of  stools  or 
vomitus;  examination  of  the  ma- 
ternal milk;  analysis  and  proper 
modification  of  cow's  milk. 

UTERINE  DISEASES — Study  of  dis- 
charges ;  section  and  examination 
of  curettings. 

PREGNANCY — Periodical  examinations 
of  the  urine,  with  special  reference 
to  the  quantity  of  urea;  tests  for 
albumose  when  death  of  infant  is 
suspected. 

DRINKING  WATER — Examination  for 
evidences  of  sewage  contamination ; 
detection  of  lead  from  water  pipes; 
the  more  complex  problems  in 
sanitation. 


CHAPTER  XVIII. 
GENERAL  INFORMATION. 

For  the  convenience  of  the  reader,  the  first  portion  of  this  chap- 
ter has  been  devoted  to  a  study  of  the  physical  and  chemical 
properties  of  certain  substances.  All  stains 
and  reagents  described  in  this  book,  as  well  as 
the  more  common  poisons,  are  considered  and 
alphabetically  arranged  for  ready  reference. 


STAINS,  REAGENTS,  AND  OTHE2 
CHEMICALS. 

ACACIA — Gum  arabic  is  soluble  in  2  parts  of 
water,  forming  a  thick  liquid;  insoluble  and 
incompatible  with  alcohol,  ether,  oils,  mineral 
acids,  ammonia,  and  tartar  emetic. 

ACETANILID — Soluble  in  2.5  parts  of  alcohol, 
but  almost  insoluble  in  water ;  dissolves  readily 
in  ether  and  chloroform;  incompatible  with 
chloral,  phenol,  resorcin,  thymol,  and  aqueous 
solutions  of  alkali  bromides  and  iodides. 

ACID,  ACETIC — Possesses  the  general  prop- 
erties of  all  mineral  acids. 

ACID,  CARBOLIC — Is  not  a  mineral  acid;  pos- 
sesses a  characteristic  odor;  is  freely  soluble 
in  glycerin,  alcohol,  ether,  and  chloroform ; 

B  --  U- -4jJ  soluble  in  about  20  parts  of  water  and  in  2 

A  —  ^k_^x  parts  of  sweet  oil. 

Fig.  43. — Five-inch  test        ACID,  CHROMIC — Is  really  not  an  acid,  but 

tube     (enlarged    one-  .  . 

third),  with  various    chromium  tnoxid ;  is  soluble  in  water,  but  not 

amounts  of  liquid.     In  ,.-...,.  . 

qualitative  work  ap-    to  be  mixed  with  glycerin  or  other  organic  sub- 
proximate    amounts.  .  T     i          •  ,  M  i         -ji 

are  always  meant  un-  stances,  as  it  explodes ;  incompatible  with  alco- 

less      otherwise      em-    ,     .          .  -  i          n         • 

phasized.    A,  5  gtt.;  hoi,  ether,  and  nearly  all  mineral  salts:  must 
c!  i1 3°or  eo  gft. gtt' :    be  kept  tightly  corked  and  free  from  moisture. 

186 


GENERAL   INFORMATION.  187 

ACID,  HYDROCHLORIC — A  true  mineral  acid;  volatile,  and  must  * 
be  kept  corked;  should  be  isolated  from  bottles  containing  am- 
monium hydroxid,  as  the  chemical  combination  of  these  gases  in 
the  air  results  in  the  formation  of  solid  ammonium  chlorid,  spread- 
ing a  white  coating  over  all  laboratory  glassware;  incompatible 
with  alkalies,  silver  salts,  chlorides,  chromates,  oxides,  permanga- 
nates, lead  salts,  etc. 

ACID,  HYDROCYANIC — An  organic  compound,  soluble  in  all  ordi- 
nary reagents,  but  used  very  rarely,  as  inhalation  of  its  vapor 
causes  instant  death. 

ACID,  NITRIC — A  true  mineral  acid ;  must  not  be  mixed  with  alco- 
hol. 

ACID,  PICRIC — A  carbolic  acid  derivative,  soluble  in  100  parts  of 
water;  incompatible  with  all  oxidizable  substances,  gelatin,  albu- 
min, alkaloids,  etc. ;  explosive  with  sulphur  and  phosphorus. 

ACID,  SULPHANILIC — Soluble  in  warm  water,  but  not  in  alcohol, 
etc. ;  usually  purchased  ready  for  the  diazo  test,  but  this  solution 
may  be  prepared  by  dissolving  1  gram  of  sulphanilic  acid  in  50  cc. 
of  concentrated  hydrochloric  acid  and  making  up  the  quantity  with 
distilled  water  to  1,000  cc. 

ACID,  SULPHURIC — A  true  mineral  acid ;  water  or  substances  con- 
taining water  must  not  be  added  to  it ;  when  necessary  to  dilute  it, 
add  it  slowly  to  the  required  amount  of  water,  constantly  stirring 
or  otherwise  mixing. 

ALCOHOL,  ETHYL — Freely  miscible  with  water,  ether,  etc. ;  not  to 
be  mixed  with  nitric  acid,  as  it  will  explode;  incompatible  with 
a"acia,  albumin,  chromic  acid,  permanganates,  etc.;  'volatile  and 
inflammable. 

ALCOHOL,  FUSEL  (FUSEL  OIL) — Mixture  of  the  higher  alcohols,  es- 
pecially amyl. 

ALCOHOL,  METHYL — Volatile  and  inflammable;  poisonous  when 
drank  or  even  when  inhaled  in  considerable  quantity. 

ALUM-CARMINE — A  nuclear  stain,  which  should  be  purchased 
ready  for  use,  but  may  be  made-up  as  follows:  to  100  cc.  of  water 
add  from  3  to  5  percent  of  ordinary  alum  and  1  gram  of  carmine, 
which  is  to  be  boiled  fifteen  minutes  and  filtered  after  cooling,  after 
which  the  solution  is  again  made  up  to  100  cc.  by  the  addition  of 
distilled  water  to  replace  that  lost  by  boiling  and  filtering. 

AMMONIUM  HYDRATE  OR  AMMONIA  HYDROXID — An  aqueous  solu- 
tion of  ammonia  gas;  explodes  when  suddenly  mixed  with  strong 


188  LABORATORY    METHODS. 

mineral  acids ;  to  be  kept  tightly  corked  and  at  some  distance  from 
the  bottle  of  hydrochloric  acid. 

AXTIPYRIN — Easily  dissolved  in  water  and  the  ordinary  solvents, 
but  incompatible  with  the  majority  of  reagents  and  drugs. 

ARSENIC  TRIOXID — Soluble  in  about  5  parts  of  glycerin;  freely 
soluble  in  hydrochloric  acid,  strong  alkalies,  and  alkaline  carbon- 
ates ;  very  slightly  soluble  in  water  and  alcohol ;  incompatible  with 
salts  of  iron  and  magnesium  and  tannic  acid. 

ATROPIN  SULPHATE — Very  soluble  in  water  and  alcohol. 

AZOLITMIN — Purified  litmus. 

BENZIDIN — Slightly  soluble  in  water ;  freely  soluble  in  alcohol  or 
ether. 

CALCIUM  CHLORID — Very  soluble  in  water  or  alcohol ;  very  deli- 
quescent. 

CANADA  BALSAM — Should  be  paper  filtered  and  colorless — not  yel- 
low ;  is  not  miscible  with  water  or  alcohol,  but  with  the  volatile  oils, 
chloroform,  and  ether. 

CARBOL-XYLOL — Add  1  part  of  pure  phenol  to  3  parts  of  pure 
xylol  and  mix  thoroughly. 

CARBOL-GENTIAN  VIOLET — Should  be  purchased  ready  for  use  in 
ounce  bottles.  Some  workers  prefer  to  use  carbol-fuchsin,  which 
may  also  be  purchased  in  liquid  form  ready  for  use. 

CELrLoiDiN — Shering's  celloidin  shreds  are  sold  in  ounce  bottles, 
and  the  substance  is  usually  kept  under  water  until  the  solutions 
are  needed;  it  is  freely  soluble  in  alcohol  and  ether,  and  the  solu- 
tions are  highly  inflammable;  directions  for  preparing  celloidin 
solutions  will  be  found  in  Essence  of  Tissue  Diagnosis,  page  82. 

CHARCOAL — Keep  well  corked,  as  it  readily  absorbs  gases;  much 
of  the  charcoal  on  the  market  is  already  thoroughly  saturated  and 
practically  valueless. 

CHLORAL  HYDRATE — Easily  dissolved  by  all  the  common  solvents, 
but  incompatible  in  alcoholic  solutions,  and  can  not  be  mixed  with 
many  other  drugs;  takes  up  water  easily,  and  should  be  kept  well 
stoppered. 

CHLOROFORM — Slightly  soluble  'in  water,  and  on  account  of 
greater  specific  gravity  forms  an  under  layer;  soluble  in  alcohol, 
ether,  and  volatile  oils :  must  be  kept  in  brown  bottles  and  well 
stoppered,  so  that  its  fumes  may  not  come  in  contact  with  the  free 
flame,  as  chlorin  is  thus  rapidly  formed. 


GENERAL   INFORMATION.  189 

COCAIN,  HYDROCHLORID — Freely  soluble  in  water,  alcohol,  and 
chloroform. 

COPPER  SALTS — Soluble  in  water  and  alcohol,  usually  forming 
blue  solutions. 

DIMETHYLAMIDOAZOBENZOL — Should  be  purchased  ready  for  use 
in  ounce  bottles  of  .5-percent  solution. 

DISTILLED  WATER — Easily  obtained  at  exceedingly  low  prices 
from  druggists;  should  be  kept  well  stoppered  and  in  a  dry  place. 

EOSIN,  YELLOW — Should  be  purchased  ready  for  use  in  ounce  bot- 
tles ;  several  drops  added  to  a  watch  glass  of  distilled  water  usually 
give  a  strong  stain. 

ETHER — Miscible  with  alcohol,  chloroform,  and  oils;  slightly 
soluble  in  water,  the  excess  forming  an  upper  layer;  very  volatile 
and  inflammable. 

ETHYL  CHLORID — Usually  comes  in  a  tube  fitted  with  a  valve  for 
releasing;  is  highly  volatile  and  inflammable;  the  tube  should  be 
slightly  warmed  in  order  to  hasten  the  flow  of  the  gas,  but  an  ex- 
plosion would  quickly  follow  the  application  of  a  high  temperature. 

FERRIC  CHLORID — Soluble  in  water  and  alcohol;  crystals  must  be 
kept  well  stoppered  and  in  a  dry  place. 

FORMALIN — Formalin  is  a  40-percent  aqueous  solution  of  formal- 
dehyd  gas ;  miscible  in  alcohol  and  water  in  all  proportions ;  forms 
explosive  mixtures,  and  incompatible  with  ammonia,  alkalies,  tan- 
nin, gelatin,  and  salts  of  iron,  copper,  and  silver;  to  be  kept  well 
stoppered. 

GLYCERIN — Miscible  in  all  proportions  with  water  and  alcohol; 
forms  explosive  mixtures  with  permanganates  and  other  oxidizing 
reagents. 

GUNZBURG'S  REAGENT — A  solution  of  2  grams  of  phloroglucin  and 
I  gram  of  vanillin  in  30  grams  of  alcohol;  should  be  purchased 
ready  for  use  in  ounce  bottles. 

HAINES'  SOLUTION — A  solution  of  2  grams  of  copper  sulphate, 
20  grams  of  glycerin,  and  9  grams  of  potassium  hydrate  in  175 
grams  of  water ;  test  samples  by  heating — if  a  reduction  takes  place 
and  a  brown  precipitate  appears,  the  reagent  is  to  be  cast  aside  as 
worthless ;  to  be  kept  in  a  dark  place. 

UAYEM'S  SOLUTION — This  may  be  easily  prepared  by  the  local 
druggist  as  follows :  mix  together  about  i/o  gram  of  pure  bichlorid 
of  mercury,  5  grams  of  sodium  sulphate,  and  1  gram  of  sodium 


190  LABORATORY    METHODS. 

chlorid;  dissolve  in  enough  distilled  water  to  make  200  cc.,  and 
filter  if  necessary. 

HEMALUM — Should  be  purchased  ready  for  use  in  ounce  bottles. 

HYDROGEN  DIOXID — Miscible  in  water  and  alcohol;  incompatible 
with  most  chemicals ;  to  be  kept  cool  and  quiet. 

IODOFORM — Soluble  in  ether,  oils,  and  boiling1  water ;  incompati- 
ble with  balsam  of  Peru,  tannin,  salts  of  silver  and  mercury,  and 
certain  other  chemicals  not  commonly  used. 

LEAD  ACETATE  OR  SUGAR  OP  LEAD — Sparingly  soluble  in  water  and 
alcohol,  but  extremely  soluble  in  either  when  heated  to  boiling: 
incompatible  with  many  mineral  salts. 

LO"FFLER'S  METHYLENE  BLUE — Should  be  purchased  ready  for 
use  in  ounce  bottles;  it  is  a  solution  of  methylene  blue  to  which 
potassium  hydrate  has  been  added. 

MARX'S  FLUID — See  Vascular  Dramas,  page  68. 

MERCURIC  CHLORID  OR  CORROSIVE  SUBLIMATE — Fairly  soluble  in 
water  and  alcohol,  especially  when  these  have  been  heated  to 
boiling;  incompatible  with  the  salts  of  many  metals,  tannic 
acid,  etc. 

MERCUROUS  CHLORID  OR  CALOMEL — Practically  insoluble  in  ordi- 
nary reagents. 

METHYLENE  BLUE — Soluble  in  water;  less  readily  in  alcohol; 
should  be  purchased  ready  for  use  in  liquid  form  in  ounce  bottles. 

METHYL  GREEN — Aqueous  solution  containing  1  percent  acetic 
acid. 

MORPHIN  SULPHATE — Soluble  in  water,  especially  when  hot : 
sparingly  soluble  in  alcohol;  incompatible  with  salts  of  metals, 
alkalies,  iodides,  tannic  acid,  etc. 

NESSLER'S  REAGENT — A  solution  of  10  grams  of  potassium  iodid, 
5  grams  of  mercuric  chlorid,  and  32  grams  of  potassium  hydrate  in 
distilled  water  to  make  200  cc. 

NEUTRAL  RED — Soluble  in  alcohol  or  water. 

OIL  SPEARMINT — A  true  volatile  oil. 

OPIUM — Soluble  in  alcohol,  which,  when  in  excess,  permits  the 
addition  of  a  certain  amount  of  water  without  precipitation ;  in- 
compatible with  alkalies,  silver  nitrate,  and  alkaloidal  precipitants. 

PHENACETIN — Fairly  soluble  in  alcohol,  but  hardly  in  water. 

PHENOLPHTHALEIN — Easily  soluble  in  alcohol,  but  not  in  water 
unless  small  amounts  of  alkali  are  added. 

PHOSPHORUS — Slightly  soluble   in  alcohol,   especially  when   the 


GENERAL   INFORMATION.  191 

latter  is  hot,  but  almost  insoluble  in  water ;  soluble  in  the  fixed  oils 
and  freely  soluble  in  carbon  disulphid. 

POTASSIUM  CHROMATE — Soluble  in  water,  but  not  in  alcohol. 

POTASSIUM  BICHROMATE  OR  POTASSIUM  DICHROMATE — Soluble  in 
water,  especially  when  the  latter  is  heated;  practically  insoluble  in 
alcohol. 

POTASSIUM  HYDRATE — A  caustic  alkali  easily  dissolved  by  water 
or  alcohol. 

SILVER  NITRATE — Very  soluble  in  water  and  fairly  soluble  in  alco- 
hol ;  soluble  in  5  parts  of  distilled  water ;  incompatible  with  salts  of 
metals,  tannic  acid  series,  organic  substances,  and  aqueous  solutions 
of  vegetable  drugs;  keep  in  brown  bottle  protected  from  light. 

SODIUM  CHLORID — Very  soluble  in  water,  but  almost  insoluble  in 
alcohol ;  incompatible  with  alcohol,  silver  nitrate,  and  certain  salts 
of  lead  and  mercury. 

SODIUM  CITRATE — Exceedingly  soluble  in  water;  slightly  soluble 
in  alcohol. 

SODIUM  NITRITE — Easily  soluble  in  water;  slightly  soluble  in 
alcohol;  incompatible  with  many  chemicals;  to  be  kept  well  stop- 
pered. 

STRYCHNIN  SULPHATE — Fairly  soluble  in  water,  especially  when 
the  latter  is  heated  or  glycerin  is  added. 

STANNOUS  CHLORID — Very  soluble  in  water ;  fairly  soluble  in  alco- 
hol ;  to  be  kept  well  stoppered. 

SULPHANOL — Fairly  soluble  in  hot  water  or  alcohol,  but  spar- 
ingly when  these  solvents  are  very  cold. 

SWEET  OIL — A  true  fixed  oil,  which  becomes  rancid  on  exposure 
to  light  and  air. 

THIONIN — Soluble  in  water,  but  concentrated  solutions  usually 
require  filtration  at  intervals. 

TINCTURE  TURMERIC — An  alcoholic  solution  of  curcuma ;  to  be 
kept  in  a  dark  place. 

UROTROPIN  OR  HEXAMETHYLENAMINE — Soluble  in  water,  but  not 
in  other  reagents;  tablets  burn  in  the  air  with  a  hot,  colorless 
flame. 

ZINC — This  must  be  chemically  pure,  or  at  least  arsenic  free; 
should  be  purchased  in  the  form  of  short  sticks;  zinc  dust  to  be 
used  when  making  up  Meyer's  blood  test  solution;  to  be  kept  well 
stoppered.  See  The  Urine  in  Disease,  footnote  on  page  119. 

WRIGHT'S  BLOOD  STAIN — Should  be  purchased  ready  for  use  in 


192 


LABORATORY    METHODS. 


liquid  form  in  ounce  bottles;  to  be  discarded  as  soon  as  a  precipi- 
tate forms  ;  precipitation  to  be  avoided  by  controlling  evaporation  ; 
to  be  kept  well  stoppered. 


WEIGHTS  AND  MEASURES. 

Apothecaries'  Weight. 

20  grains    ...........................    =  1  scruple. 

3  scruples     .........................    —  1   din  in. 

8  drams    ...........................    =  1  ounce. 

12  ounces      ..........................   =  1  pound. 

Apothecaries'  Measure. 

60  minims    ..........................  :—  1   fluidram. 

8  fluidrams    ........................  =  1   fluidounce. 

16  fluidounces   .......................  =  1  pint. 

8  pints    ............................  =  1  gallon. 

Equivalents. 

1  grain    ............................  ==  60  milligrams. 

15  minims      .........................  —  1  cubic  centimeter. 

15  grains    ...........................  =  1  grain. 

1  dram    ............................  =  4  grams. 

1   fluidram    .........................  =  4  cubic  centimeters. 

1   fluidounce   ........................  =  32  cubic  centimeters. 

1  ounce     ...........................  =  .'52  grams. 

1  quart   .........................  ...  —  1   liter. 

A  teaspoon  contains  about  1%  fluidrams,  a  dessert  spoon  about 
fluidrams,  and  a  tablespoon  about  5  fluidrams. 


MISCELLANEOUS. 

Drop  Method  for  Preparing  Approximate  Percentage  Solutions. 
—In  qualitative  analysis  (but  not  in  therapeutics)  we  may,  when 
considering  aqueous  solutions,  use  the  terms  "drop"  and  "minim'' 
synonymously,  and  this  method  gives  fairly  accurate  percentage 
solutions.  For  example,  suppose  a  10-percent  solution  of  silver 
nitrate  is  desired.  This  substance  is  soluble  in  one-half  its  volume 
of  water,  or  each  drop  of  a  concentrated  solution  in  distilled  water 
contains  approximately  2  grains;  or,  to  state  it  in  other  terms,  to 
each  of  these  drops  must  be  added  19  drops  more  of  the  water  to 


GENERAL   INFORMATION. 


193 


obtain  the  desired  percentage.  This  method  does  not,  however, 
answer  for  quantitative  tests,  nor  for  mixtures  intended  for  thera- 
peutic purposes. 

Fahrenheit  and  Centigrade  Equivalents. — On  the  Fahrenheit 
thermometer  the  space  between  freezing  and  boiling  points  is  di- 
vided into  180  equal  parts  or  degrees,  the  zero  point  being  32  de- 
grees below  the  freezing  of  water.  On  the  Centigrade  thermometer 
the  space  between  freezing  and  boiling  points  is  divided  into  100 
parts  or  degrees,  the  zero  point  being  at  the  freezing  of  water.  A 
degree  of  Fahrenheit  is  therefore  %  degree  of  Centigrade.  The 
following  are  simple  rules  for  the  conversion  of  temperature  of 
Fahrenheit  to  Centigrade  and  Centigrade  to  Fahrenheit : 


ABOVE  32°  F.  AND  0°  C. 


FAHRENHEIT  TO  CENTIGRADE. — Subtract  32,  multiply  by  5,  divide 
by  9. 

CENTIGRADE  TO  FAHRENHEIT. — Multiply  by  9,  divide  by  5,  add  32. 


Fahrenheit  to  Centigrade. 
50°  F. 
32 


18 
5 


9)90(10°  C. 


Centigrade  to  Fahrenheit. 
10°  C. 


5)90(18 
32 


50°  F. 


The  examples  show  that  50°  F.  above  0°  equals  10  C.°  above  0°, 
and  vice  versa. 

BELOW  32°  F.  AND  0°  C. 

FAHRENHEIT  TO  CENTIGRADE. — Subtract  from  32,  multiply  by  5, 
divide  by  9. 

CENTIGRADE  TO  FAHRENHEIT. — Multiply  by  9,  divide  by  5,  sub- 
tract from  32. 


Fahrenheit  to  Centigrade. 
32 

r>°   F. 


9)135(15°  C. 


Centigrade  to  Fahrenheit. 
15°  C. 
9 


5)135(27  from  32 

27 


5°  F. 


The  examples  show  that  5°  F.  above  0°  equal  15°  C.  below  0°, 
and  vice  versa. 


194  LABORATORY   METHODS. 

Spoon  Urinalyses. — These  analyses  have  been  popular  with  the 
general  practitioner  as  bedside  tests,  and  give  fairly  good  results. 
but  are  not  to  be  compared  with  the  urinalyses  described  in  this 
book  (page  111).  The  following  tests  are  quoted  from  Richter, 
as  the  necessary  apparatus  may  not  be  at  hand,  but  they  would  not 
be  accepted  by  any  insurance  company  nor  by  any  high  authority 
in  a  consultation. 

To  test  for  albumin,  take  a  half  teaspoonful  of  urine,  add  a  small 
pinch  of  salt,  and  heat  over  a  lamp  or  match.  When  it  begins  to 
steam  and  bubble,  add  a  few  drops  of  vinegar  and  watch  for  pre- 
cipitate. 

To  test  for  glucose,  dilute  1  or  2  drops  of  the  urine  with  a  few 
drops  of  water  in  a  spoon.  Carefully  evaporate  to  dryness  with  a 
little  heat.  Now  again  slowly  heat,  when  almost  suddenly  a  char- 
acteristic orange-brown  spot  and  an  unmistakable  odor  of  caramel 
will  prove  the  presence  of  sugar.  One-third  of  1  percent  is  easily 
detected  in  this  manner.  Urine  free  from  sugar  colors  a  smoky 
black,  and  on  further  heating  emits  its  peculiar  urinous  odor. 

Deodorizers. — Previous  references  have  been  made  to  this  sub- 
ject and  certain  formulas  presented  (page  24).  The  burning  of 
sugar  or  rags,  as  practiced  by  the  housewife,  is  efficient,  not  only 
because  of  its  "counter  odor,"  but  for  the  reason  that  the  carbon 
thus  formed  in  its  heated  or  nascent  state  readily  absorbs  obnoxious 
gases.  Foul  odors  from  certain  substances  may  be  covered  up  by 
certain  volatile  oils,  notably  cassia  and  bergamot. 

To  Remove  Rust  from  Instruments. — Broder's  method  will  be 
of  value  to  the  surgeon  as  well  as  the  analyst  who  desires  that  his 
outfit  present  the  best  possible  appearance.  Fill  a  suitable  vessel 
with  a  saturated  solution  of  chlorid  of  tin  in  distilled  water,  im- 
merse the  rusty  instruments,  and  let  them  remain  over  night.  Rub 
dry  with  chamois  after  rinsing  in  running  water. 

To  Remove  Stains  from  Fingers. — Anilin  dye  stains  may  be 
quickly  removed  from  the  fingers  by  washing  with  a  cloth  damp- 
ened in  a  solution  of  4  parts  alcohol  and  1  part  ether. 

Mineral  acid  stains  and  those  caused  by  potassium  permanganate 
may  require  several  good  scrubbings  in  hot  soapsuds  before  they 
disappear. 


APPENDIX. 

Being  a  concise  report  of  recent  and  more  special  laboratory  methods  which 
by  virtue  of  their  simplicity  and  usefulness  will  appeal  as  practical  to  the 
man  who  desires  to  go  somewhat  more  deeply  into  this  enticing  department 
of  medicine. 

Bedside  Estimation  of  Urinary  Acidity. — Reference  has  been 
made  to  the  significance  and  estimation  of  urinary  acidity  (pages 
109  and  123).  To  avoid  the  tedious  buret  method  of  titration, 
Harrower  has  devised  a  simple  instrument  in  the  form  of  a  gradu- 
ated test  tube  of  heavy  glass.  This  may  be  carried  in  the  phy- 
sician's handbag  and  the  estimations  made  at  the  bedside  of  the 
patient.  The  physician  has  only  to  fill  the  tube  with  the  urine 
up  to  the  10  cc.  mark,  add  a  couple  drops  of  phenolphthalein  so- 
lution and  then  the  decinormal  sodium  hydrate  solution  drop 
by  drop,  shaking  well  after  each  addition  until  the  first  perma- 
nent pink  is  obtained.  The  percentage  is  then  read  off  directly 
from  the  scale  on  the  side  of  the  tube.  By  keeping  track  of  the 
amount  of  urine  passed  daily,  estimation  may  be  quickly  made 
of  the  total  quantity  of  acid  excreted  in  that  time. 

Significance  of  Indicanuria. — Indican  is  not  a  normal  constitu- 
ent of  the  urine  but  occurs  as  a  result  of  proteid  decomposition 
at  some  point  in  the  body.  Thus  in  the  purulent  conditions,  e.  g., 
hidden  abscess,  the  presence  of  indican  in  the  urine  may  lead  us 
to  diagnosticate  the  condition.  In  malignant  growths  where  a 
considerable  degree  of  degeneration  and  necrosis  is  present,  in- 
dican may  appear  in  the  urine  in  large  amounts;  but  if  we  can 
rule  out  these  two  sources  of  indican,  we  have  still  to  reckon  with 
another  of  considerable  importance;  viz.,  bacterial  decomposition 
of  proteid  foodstuffs  in  the  colon.  In  other  words,  by  the  de- 
tection of  indican  in  the  urine  of  a  person  in  whom  hidden  pus 
or  other  degenerative  changes  are  unlikely,  we  gain  easily  and 
quickly  evidences  that  affairs  in  the  large  bowel  are  not  as  they 
should  be,  and  that  it  is  time  that  this  natural  incubator  be 
cleaned  out. 

195 


196  APPENDIX. 

The  finding  of  excessive  amounts  of  acid  in  the  urine  furnishes 
further  proof,  but  if  such  is  not  present,  we  are  scarcely  justi- 
fied in  concluding  at  once  that  the  indican  does  not  come  from 
the  colon.  The  acids  accompanying  such  a  condition  may  be 
well  cared  for  by  the  neutralizing  precursors  of  urea;  but  noth- 
ing is  present  to  render  inactive  the  telltale  indican. 

While  it  is  not  the  aim  of  the  authors  to  delve  deeply  into  the 
mysteries  of  indican  chemistry,  another  word  must  be  added  to 
complete  the  diagnostic  and  prognostic  consideration  of  1hn 
body.  INDICAN  IS  NOT  A  NORMAL  CONSTITUENT  OF  THE 
URINE,  let  it  be  repeated.  In  case  pyogenic  processes  in  the 
tissues  (pyorrhea  alveolaris,  otitis  media,  septic  tonsils,  sinusitis, 
tuberculous  cavities  in  the  lungs,  empyema,  gall  bladder  abscess, 
chronic  appendicitis,  salpingitis,  pyelitis  and  chronic  gonorrheal 
prostatitis)  neoplasms  and  true  copremia  are  finally  ruled  out, 
we  have  not  yet  finished  our  search  for  the  source  of  urinary 
indican.  Few  of  us  are  entirely  normal:  a  gastric  hypoacidity 
may  interfere  with  the  proper  digestion  of  the  proteids;  or  we 
may  be  taking  too  much  proteid  food.  In  such  cases,  however, 
the  indican  usually  occurs  in  merest  traces,  so  that  a  consider- 
able amount  of  this  substance  always  means  a  strictly  pathological 
condition.  For  copremia  is  not  to  be  regarded  lightly,  it  being 
quite  possible  that  the  poisons  absorbed  from  the  bowel  are 
highly  toxic  to  the  kidney  tissue  and  may  have  much  to  do  with 
the  etiology  of  Bright 's  disease. 

Furthermore,  a  mere  cleaning  out  of  the  colon  may  not  cause 
a  disappearance  of  the  urinary  indican;  but  such  circumstance 
does  not  prove  that  the  condition  is  not  copremia.  The  same 
microorganisms  quickly  proliferate  to  numbers  equal  to  those 
first  attracting  our  attention.  The  bowel  must  be  kept  reno- 
vated and  a  new  flora  (e.  g. — the  Bulgarian  bacillus)  introduced. 
Reduce  also  the  proteid  diet,  and  if  these  measures  fail  to  re- 
duce the  indican,  it  is  very  likely  that  proteid  decomposition  in 
the  tissues  is  responsible  for  the  indican.  This  substance  occurs 
in  large  amounts  in  enteroptosis  inasmuch  as  the  bowel  bacilli 
have  ample  opportunity  to  proliferate  and  decompose  the  pro- 
teids. The  same  may  be  said  concerning  intestinal  obstruction 
or  fecal-clogged  colon. 

Detection  of  Indican. — The  following  method  has  been  recom- 
mended by  Dr.  Harrower  and  others,  and  is  simple  as  well  as 


APPENDIX.  197 

reliable :  To  one  dram  of  the  urine,  add  one  dram  of  pure  hy- 
drochloric acid,  one  half  dram  of  chloroform  and  two  or  Ihree 
drops  of  reliable  hydrogen  peroxide.  Shake  well  for  a  minute 
and  set  aside.  If  a  reaction  fails  to  appear,  shake  again  and 
set  aside.  The  quantities  of  liquids  used  need  not  be  accurate, 
but  should  be  approximately  so. 

The  chloroform  dissolves  the  indigo  which  has  been  liberated 
by  the  action  of  the  acid  and  peroxide ;  and  as  it  sinks  to  the 
bottom  of  the  tube,  a  blue  or  violet  color  is  noted,  the  intensity 
of  the  tint  varying  directly  with  the  amount  of  indican  in  the 
urine.  Thus  we  speak  of  a  trace,  a  small  amount,  a  moderate 
amount,  a  large  amount,  and  a  tremendous  amount — although 
we  have  no  very  reliable  method  of  estimating  the  degree  of  in- 
dicanuria.  Sometimes  a  permanent  red  color  may  take  the  place 
of  the  blue  in  the  chloroform,  and  this  is  called  red  indican.  Red 
indican  probably  always  comes  from  the  bowel,  bearing  a  relation 
to  skatol  not  unlike  that  which  indican  bears  to  indol.  It  is 
more  likely  to  arise  from  the  decomposition  of  vegetable  protcids 
in  the  colon;  and  such  patients  are  usually  irritable  whereas 
those  with  blue  indican  are  depressed. 

Sources  of  Error. — Inquire  concerning  the  administration  of 
potassium  iodid,  salicylic  acid  and  urotropin  as  these  may  give 
pseudoreactions.  Such  drugs  should  be  omitted  before  testing 
the  urine.  Iodid  of  potash  imparts  to  the  chloroform  a  rose-red 
color;  but  this  may  be  driven  away  by  shaking  with  a  few  drops 
of  alcohol  or  sodium  hyposulphite,  whereas  the  true  red  indican 
is  refractory  to  these  reagents. 

The  urine  should  be  fairly  fresh  and  should  contain  no  pre- 
servatives. Often  the  supernatent  liquid  becomes  of  a  dark 
color,  but  the  chloroform  does  not  seem  to  be  able  to  dissolve  this 
indigo.  In  such  case,  add  one-half  dram  of  alcohol  when  upon 
shaking,  solution  will  be  effected  by  the  chloroform-alcohol 
mixture  and  the  heavy  layer  comes  down  blue  or  violet. 

Detection  and  Significance  of  Indolacetic  Acid. — Many  of  the 
poisonous  acids  formed  in  the  colon  and  excreted  by  the  kidney, 
baffle  accurate  identification  by  tests  applicable  in  the  physician's 
laboratory.  A  notable  exception  is  indolacetic  acid  which  may  or 
may  not  be  formed  in  the  copremic  process.  Its  significance  is 
the  same  as  that  of  indican,  though  either  may  be  present  with- 
out traces  of  the  other  being  found.  To  test  for  this  substance, 


198  APPENDIX. 

add  to  about  one  dram  of  the  urine,  one  drop  of  a  one  percent 
solution  of  potassium  nitrite  and  a  few  drops  of  hydrochloric 
acid.  If  positive,  a  pink  color  is  noted,  which  varies  in  intensity 
directly  with  the  amount  of  indolacetic  acid  present.  As  soon 
as  the  color  is  or  is  not  noted,  the  test  may  be  finished  for  indican 
with  the  same  sample  as  directed  a"bove. 

Significance  and  Detection  of  the  Bence-Jones  Body. — The 
finding  of  this  substance  in  the  urine  may  be  regarded  as 
pathognomonic  of  multiple  myelomata.  Exceptions  have  been 
claimed,  but  these  must  be  very  few  in  number.  Acidify  the 
urine  if  necessary.  If  it  is  not  clear,  filter  it.  Heat  a  specimen 
in  a  test  tube.  When  it  becomes  quite  warm — almost  hot — a 
marked  turbidity  or  cloudiness  may  be  observed  which  grows 
more  and  more  intense  as  the  temperature  approaches  boiling; 
but  as  ebullition  begins,  the  urine  begins  to  clear;  and  when  it 
boils  the  cloudiness  wholly  or  nearly  disappears.  Now  if  the 
contents  be  allowed  to  cool,  the  turbidity  reappears. 

Sulphosalicylic  Acid  Test  for  Urinary  Albumin. — Physicians 
are  loath  to  carry  nitric  acid  in  their  handbags;  and  in  many 
cases  a  strong  aqueous  solution  of  sulphosalicylic  acid  may  an- 
swer equally  well.  This  reagent  should  not  be  concentrated,  in- 
asmuch as  many  crystals  are  deposited  in  the  bottom  of  the  vial 
and  may  interfere  with  the  test.  It  is  well  to  keep  the  vial 
tightly  stoppered  as  evaporation  appears  to  encourage  the  depo- 
sition of  these  crystals. 

This  is  a  very  sensitive  test  for  serum  albumin.  It  is  to  be 
carried  out  at  room  temperature — i.  e.,  the  urine  and  the  reagent 
are  not  to  be  heated.  To  one  dram  of  the  urine  (filtered  if  not 
clear),  add  a  couple  of  drops  of  the  reagent  and  shake  sufficiently 
to  mix.  Hold  in  the  light  and  watch  for  the  appearance  of  a 
cloudiness.  This  usually  manifests  itself  promptly,  but  may  be 
delayed.  In  case  of  question,  add  a  few  more  drops  of  the  re- 
agent. Rarely  more  than  five  drops  will  be  required  for  a  dram 
of  urine.  Compare  with  some  of  the  urine  to  which  the  reagent 
has  not  been  added. 

This  test  may  be  applied  to  a  clear,  unfiltered  urine  or  to  one 
which  comes  through  the  filter  clear;  and  this  statement  applies 
to  most  urines,  although  occasionally  a  specimen  cannot  be 
cleared  by  filtration.  In  such  contingency,  the  test  is  scarcely 
applicable  and  we  must  fall  back  upon  the  older  methods. 


APPENDIX.  199 

Hermann-Perutz  Serum  Test  for  Syphilis. — At  present  the 
Wassermann  is  denied  the  busy  practitioner,  as  considerable  time 
and  experience  is  necessary  for  its  completion.  The  Hermann- 
Perutz  reaction  was  devised  to  fill  this  want ;  and  though  a  new 
test,  it  bids  fair  to  find  a  permanent  post  in  the  physician's  labo- 
ratory. This  reaction  requires  for  its  completion  but  three  ele- 
ments, viz. — 

1.  Reagent  A. 

Sodium    glycocholate     2.0 

Cholesterin     0.4 

Ninety-five    percent,    alcohol    100.0 

2.  Reagent  B. 

A  two-percent  aqueous  solution  of  sodium  glycocholate. 

3.  Specimen  for  examination. 

Fresh  blood  serum  from  the  patient. 

The  reagents  should  be  prepared  just  before  the  test  is  set  up. 
Some  blood  from  the  patient's  ear  or  finger  is  collected  in  a 
sterile  test  tube  and  slanted  in  an  icebox  over  night.  (A  vacuum 
bottle  with  some  bits  of  ice  will  serve  equally  well.)  In  the 
morning  the  serum  is  collected  by  means  of  a  sterile  pipet  and 
placed  in  a  sterile  test  tube ;  and  a  sterile  cotton  plug  is  placed 
in  its  mouth.  The  first  tube  and  clot  are  of  no  further  use  in  the 
test.  The  serum  is  now  "inactivated"  by  placing  in  an  incubator 
(or  vacuum  bottle)  at  132-133  degrees  F.  for  thirty  minutes. 
Before  the  test  is  set  up,  dilute  Reagent  A  with  sterile  distilled 
water  in  proportion  of  1 :20. 

In  a  third  small,  sterile  test  tube  mix  .4c.c.  of  the  serum  and 
.2  cc.  of  each  reagent.  These  quantities  may  easily  be  taken  up 
by  the  aid  of  an  accurately  graduated  pipet.  (The  authors  have 
obtained  excellent  results  with  5  drops  of  the  serum  and  3  drops 
each  of  the  respective  reagents;  but  the  original  method  offers 
no  great  difficulties  if  the  physician  secure  a  proper  pipet.)  The 
mixture  is  vigorously  shaken  and  then  set  aside  at  room  temper- 
ature, providing  the  room  does  not  become  chilled  or  overheated. 
The  tube  is  examined  at  frequent  intervals.  If  the  reaction  is 
positive,  a  flocculent  precipitate  will  appear.  A  control  should 
always  be  carried  out  alongside  this  test,  with  a  serum  known  to 
be  nonsyphilitic. 

Value  and  Interpretations  of  the  Hermann-Perutz  Reaction. 


200  APPENDIX. 

We  believe  that  the  meaning  of  the  positive  reaction  is  identical 
with  that  of  the  Wassermann.  If  the  reaction  is  positive,  the 
patient  has  syphilis:  if  it  is  negative,  we  are  not  certain  as  to 
the  diagnosis  and  there  is  still  a  possibility  that  he  has  syphilis. 
The  disappearance  of  the  reaction  under  mercury  or  arsenic  is 
not  proof  sufficient  that  the  patient  is  finally  cured,  although  it 
probably  shows  some  degree  of  success  in  this  direction.  Thus 
only  the  positive  reaction  is  of  value  and  this  value  is  diagnostic 
only;  and  so  far  as  we  have  conclusive  proof  is  never  prognostic. 
Apparently  the  reaction  is  as  sensitive  as  the  Wassermann ;  and 
is  doubtless  as  dependable.  .Because  of  its  comparative  sim- 
plicity, it  bids  fair  for  a  place  among  our  valuable  laboratory 
methods,  not  only  so  far  as  the  needs  of  the  general  practitioner 
are  concerned,  but  by  virtue  of  this  very  simplicity,  the  sources 
of  error  are  reduced  to  a  minimum.  Carried  out  in  connection 
with  control  serums  and  with  the  butyric  acid  test  (see  page 
99)  its  diagnostic  worth  is  great  indeed. 

Recent  Studies  in  the  Painful  Oxalurias. — Several  months  ago 
one  of  the  authors  in  a  review  of  the  oxalurias,1  showed  that  cer- 
tain cases  of  lumbar  distress  and  hematuria  may  be  explained  by 
the  mechanical  injury  to  the  mucous  membrane  of  the  urinary 
passages,  occasioned  by  the  passage  of  sharp  crystals  of  calcium 
oxalate ;  the  symptoms  increasing  in  intensity  as  larger  numbers 
of  these  crystals  are  passed.  Such  a  condition  may  be  termed 
painful  oxaluria,  oxaluria  dolorosa,  and  is  by  no  means  an  infre- 
quent one,  though  often  missed  by  the  practitioner.  The  treat- 
ment is  dietetic  and  medicinal,  never  surgical  unless  other  trou- 
bles complicate.  The  practitioner  should  remember  that  the  crystals 
of  calcium  oxalate  are  very  small ;  and  this  applies  especially  to 
those  causing  symptoms.  They  cannot  be  identified  by  the  low 
power  objectives;  and  are  often  missed  by  the  higher  powers  if 
the  worker  is  careless.  There  are  other  forms  of  oxaluria,  and 
these  are  not  associated  with  symptoms;  but  here  the  crystals 
are  neither  deposited  in  such  large  numbers  nor  so  high  in  the 
urinary  tract ;  they  are  smaller  and  their  edges  not  so  sharp  and 
their  excretion  does  not  extend  over  long  periods  of  time.  Inas- 
much as  these  crystals  are  often  found  in  fermenting  urines,  a 
fresh  sample  should  be  examined  before  an  opinion  is  ventured. 

'Medical   Record,   May   11,    1912. 


INDEX. 


Abortifacients,  composition  of,  87 
Acacia   as   a   reagent,    187 

for  tissue  sectioning,  80 
Accessories  for  laboratory,  14 
Acetanilid,  detection  of,  88 

properties   of,    186 
Acid,  acetic,  62,   186 

carbolic,    186 

chromic,   186 

hydrochloric,    75,    181 

combined,  estimation  of,  75 
free,  tests  for,  75 

hydrocyanic,  187 
cautions,   181 
detection  of,  91 

lactic,  75 

nitric,   110,   187 

picric,   187 

sulphanilic,   100,   187 

sulphosalicylic,  198 

sulphuric,  "l35,    187 
Acidemia,   123 
Acidosis,  123 
Acids,  detection  of,  88 
Actinomycosis,  49 

laboratory  aids  in,  183 
Addison's   disease,    185 
Albumin    in  urine,    109 

in  sputum,  29 
Alcohol,  187 

amyl,   187 

detection  of,  88 

ethyl,  187 

methyl,   187 

fusel,'  187 

Alcoholism,  laboratory  aids  in,  183 
Algae  in  water,  141 
Alkalies,  detection  of,  88 
Ameba  coli,  150 
Amebic  dysentery,  182 
Ammonia,  187 

detection  of,  88 
Anemia,   58 
Ankylostomiasis,    laboratory   aids  in, 

182 

Antiseptics,  definition,  177 
Apothecaries'  weight,  table  of,  192 

measure,  table  of,   192 
Apparatus.   24 

cabinet  for,  24 


2ul 


A  pparatus — cont'd. 
for  autopsies,  156 
for  bacteriological  tests,  37 
for  blood  analysis,  53,  57 
for  diazo  test,  101 
for  gastric  analysis,  71 
for  Marsh  test,  85 
for  milk  analysis,  125 
for  poison  tests,  85 
for  sputum  analysis,  27 
for  stool  tests,  148 
for  treponema  test,  171 
for  urinalysis,  107 
for  water  analysis,   144,   146 
for  Widal  reaction,  104 
Arsenic,   188 

detection  of,  89 
Arthritis  deformans,   183 
Ascaris  lumbricoides,   150 
Ascites,  97 
Atropin,  188" 

detection  of,  90 
Autopsy  prophylaxis,  1791 
technic,   156 

bacteriological,  157 

brain,   162 

chest,  164 

cord,   168 

duodenum,   167 

equipment  for,  156 

female  genitalia,   168 

heart,  165 

in  new  born,  169 

inspection,    palpation,    and    per- 
cussion, 160 

intestine,    167 

kidneys,    166 

liver,    167 

lungs,    166 

male  genitalia,  167 

meninges,   161 

microscopic  morbid  anatomy,  157 

order  of  procedure,  159 

pancreas,    167 

precautions  in,   150 

preparations  for,   157 

private*  autopsy.   156 

prophylaxis  in,  179 

special  sense  organs,  163 

spleen,   166 

stomach,  167 


202 


INDEX. 


Autopsy  technic — cont'd. 
trunk,    Ki.'J 

uncovering  the  brain,  100 
weights  and  measures,  158 

Axolitmin,   188 

in  water  analysis,  146 

Azoospermatism,  97 

B 

Bacteria,  37 

in   blood,  67 

in  exudates,  97 

in  feces,   149 

in  stomach  contents,  75 

in   urine,    121 

in  water,   142,   145 
Bacteriophobia,  177 
Bad  whisky,  composition  of,  87 
Bass  Test,   104 
Bence- Jones  body,   198 
Benzidin  in  blood  tests,  148 

properties  of,   188 
Betaoxybutyric  acid,  116 
Bilirubin  in  urine,  113 
Bitters,  composition  of,  87 
Blenorrhea,  vaginal,  98 
Blood,  53 

apparatus  for  examination  of,  53,  57. 

artifacts  in,  64 

cast,  56 

cells,  56 

cleaning  pipettes,  62 

coagulation  of,  68 

counters,  61 

counting  fluids,  61 

development  of  cells,  53 

differential  counts,  66 

diseases  of,  58 

dramas,  55,  57 

forceps  for,  65 

fowl's,  67 

hemin  tests,  67 

hemoglobin,   59 

in  exudates,  97 

in  feces,   149 

in  monoxide  poisoning,  68 

in  sputum,  32 

in  stomach  contents,  74 

in  urine,   113 

leukocytes  in,  57 

macroscopical  examination  of,  59 

microscopical  examination  of,  59 

obtaining  specimen  of,  58 

occult,  149 

parasites  in,  67 

pipettes  for,  61 

plates  in,  54 

red  cells  of,  56 

red  counting,  60 

spreading  of.   63 

staining  of,  65 

stickers  for,  57 


Blood — cont'd. 

white  cells  of,  57 
counting,  62 

Widal  tests  of,   106 
ISorax   in   milk,    135 
Boric  acid  in  milk,  135 
Boston's  test  for  albumin,  110 
Bothriocephalus  latus  in  water,  141 
Bowel  bacilli  in  water,   14f> 
Bracers,  composition  <if.   S7 
Brain  in  autopsy  technic,  1(12 
Bronchitis,  laboratory  aids  in,  184 
Burns,  treatment  of,  179 
Butyric  Acid  Test,  99 

C 

Calcium  carbonate,  120 

chlorid,   188 

as  a  reagent,  85 

oxalate,   120 

crystals  in  urine,  120 
oxaluria  dolorosa,   120,  122 
Canada  balsam,  properties  of,  188 
Cantharidin,  detection  of,  90 
Carbol-fuchsin,  31 

gentian  violet,  31 

thionin,  81 

xylol.  84,  188 
Carbolic  acid,   188 

detection  of,  90 
Caries,  99 
Casts  in  urine,  117 
Celloidin,  188 

imbedding  in,  82 
Centigrade  equivalents,   193 
Centrifuge,  14 

choice,  14 

collecting  sediment,   116 

use  in  exudates,  96 
Cerebro-spinal   fever,   laboratory   aids 
in,  183 

fluid,  97 

obtaining,  94 
examination  of,  97 
Charcoal,  properties  of,  188 
(  licst,  opening  of,  164 
Chloral,  detection  of,  90 
Chlorides  in  urine,   115 
Chlorin  estimation  in  water,   143 
Chloroform,   properties  of,   188 
Chronic  rheumatism,   183 
Clap  threads  in  urine,  117 
Cocain,  87 

detection  of,  90 
Colon   bacillus,  48 

in  water,   145 
Commercial   waters,    139 
Comparative  chlorin,   143 
Copper,  detection   of,  !)l 


INDEX. 


203 


Cord,  removal  of,  168 

Cough  syrups,  composition  of,  87 

Cover  glasses,  16,  20 

sterilization  of,  42 
Cream,  proportion  in  milk,  134 
Crystals  in  urine,   120 
Culture  media,  23,  27 
Curettings,  84 
Curschmann's  spirals,  30 

in  sputum,  33 
Cylindroids  in  urine,  118 


D 


Dead  animals  in  water,   141 
Decinormal   sodium   hydrate  solution, 

75 

Degeneration  of  red  corpuscles,  56 
Dengue,  laboratory  aids  in,  183 
Dental  caries,  99 
Deodorizers,  24,  194 
Detection  of  poisons,  85 

abortifacients,  87 

acetanilid,  88,  186 

acids,  88 

•  alcohol,  88,  187 

alkalies,  88 

ammonia,  8'8,   187 

antipyrin,  188 

apparatus  for,  85 

arsenic,  89,  188 

atropin,  90,   188 

bad  whisky,  87 

bitters,  87 

bracers,  87 

cuntharidin,  90 

carbolic  acid,  90,  186 

chloral  hydrate,  ,90,  188 

cocain,  87,  90,  189 

co.ugh  syrups,  87 

drug  cures,  87 

ergot,  91 

formalin,  91,  189 

headache  powders,  87 

hydrocyanic  acid,  91,  181,  187 

hyoscin,  90 

knock-out  drops,  87 

lead,  91,  140,  190 

liniments,  87 

lye,  88 

matches,   88 

mercury  salts,  91,  190 

morphin,  92,  190 

opium,  92,  190 

pans  green,  88 

phenol.  90 

phosphorus,  92,   190 

rat  poisons,  88 

sex  stimulants,  88 

silver  nitrate,  92,   191 


Detection — con  t'd. 

skin  beautifiers,  88 

sources  of  poisons,  87 

strychnin,  92,  191 

sulphonal,  92,  191 

trional,  92 

wood  alcohol,  187 
Diabetes  mellitus,  184 

insipidus,  184 

urine,  123 

Diacetic  acid,  tests  for,  116 
.Diazo  test  for  typhoid,  100 
Dimethylamidoazobenzol,  189 

in  stomach  analysis,  75 
Dimethylaminobenzaldehyde,  115 
Diphtheria,    183 

bacillus  of,   44 

Diplococcus     intracellularis    meningi- 
tiditis,  97 

gonorrhea,   48 

pneumonia,  33 
Diseases,   laboratory   aids   in,    182 

of  alimentary  tract  of  infant,   185 

of  arteries,  185 

of  blood,  184 

of  ear,   184 

of  eye,    185 

of   heart,    185 

of  intestine,  184 

of  kidney,  184 

of  larynx,  184 

of  lung,  184 

of  pericardium,  185 

of  pharynx,   184 

of  pleura,   184 

of    spleen,    185 

of  thymus,  185 

of  thyroid,  185 

Disinfectants,  definition  of,  177 
Distilled  water  as  a  reagent,   189 
Drop   method   of   estimating   percent- 
age solutions,  192 
Drug  cures,  composition  of,  87 
Duodenum,  examination  of,  167 

E 

Ecchinococcus  in  sputum,  33 
Ehrlich's   diazo   reaction,    100     . 
Elastic  tissue  in  sputum,  29 
Endocarditis,  malignant,   precautions, 

179 

Eosin,  68,  84 
Eosinophilia,  58 
Ergot,  detection  of,  91 
Erysipelas,  laboratory  aids  in,   183 
Erythrocytes,  56 

artifacts  of,  64 

classification  of,   56 

counting  of,  60 

development  of,  53 


204 


INDEX. 


Erythrocytes — cont'd. 

in  exudates,  97 

in  feces,   149,  154 

in  sputum,  32 

in  stomach    contents,  73 

in  urine,  113 
Essence  of  tissue  diagnosis,  78 

apparatus  for,  78,  82 

celloidin,  82 

curettings,  84 

freezer,  80 

imbedding,  83 

microtome,  79 

knife,  80 

paraffin,  84 

sectioning,  80,  83 

staining,  80 

Ether,  properties  of,  189 
Ethyl  chlorid,  properties  of,  189 
Ewald  test  breakfast,  71 
Explosive  mixtures,   180 
Exudates,  94 

abdominal,  94 

apparatus  for  examining,  94 

lumbar,  94 

preparation  of,  96 

thoracic,  94 


Fahrenheit  equivalents,  193 
Family  sterility,  97 
Fat  estimation  in  milk,  135 
Fecal  analysis,   148 

ameba  coli,  150 

apparatus,  148 

ascaris  lumbricoides,  150 

bacteria,  149 

blood,  149,  154 

color,  149 

consistency,  149 

hookworm,  152 

in  infant,  154 

obtaining  the  specimen,  148 

occult  blood,  149 

odor,  149 

ova,  153 

pinworms,  150 

tapeworms,  151 

value  and  limitations,  155 
Female  genitalia,  examination  of,  168 
Fermentation  test  for  glucose,  113 
Ferric  chlorid  solution,   189 

use  as  a  reagent,  71 
Fluorescence  test  in  water,  146 
Foam  test  for  bilirubin,  113 
Food  poisons,  183 
Foreign  matter,  118 

in  sputum,  30 

in  urine,  118,  121 


Formalin,  formaldehyde,  189 

detection  in  milk,   134 

detection  in  quantity,  91 

for  hardening  tissues,  80 
Formulas,  milk,  136 
Freezer  for  tissues,  80 
Frozen  sections,  79 

G 

Gall  stones  in  feces,   155 
Gas,  substitutes  for,  17 
Gastric  analysis,  71 

apparatus  for,  71 

blood,  73 

chemical,  75 

color,  73 

interpretation  of,   76 

macroscopic  examination,  73 

microscopic  examination,  74 

physical  characteristics,  74 

preparation  for,  71 

sources  of  error  in,  77 

value  and  limitations  of,  77 
General  considerations,  13 

information,  186 
Gentian  violet,  27 
Germicides,  177 
Germ  growth,  38* 

incubation  as  an  aid,  41 

influences  inhibiting,  38 

sterilization  of,  41 
Germs,  37 

actinomyces,  49 

apparatus  used  in  searching  for,  37 

bacillus  coli  communis,  48- 
diphtheria?,  44 
Koch -Weeks,  47 
tetani,  45 
typhosus,  48 

culture  media  for,  37 

difficulties  in  finding,  50 

gonococcus,  48 

incubation  of,  41 

inoculations  of,  40 

isolation  of  pure  cultures,  40 

molds,  49 

staphylococci,  48 

streptococcus  pyogenes,  47 
Glassware,  14 

cleaning  of,  14 

sterilization  of,  41 
Glucose  in  the  urine,  112 
Glycerin,  properties  of,  189 
Gonococcus,  searching  for,  48 
Gonorrhea,  laboratory  aids  in,  183 
Gout,  laboratory  aids  in.   1S4 
Gunzburg's  reagent  in  stomach  analy- 
sis,   75 

properties  of,  189 


INDEX. 


205 


H 

Haines'  sugar  test,  112 
Hayem's  fluid,  189 

for  counting  erythrocytes,  59 
Hay  fever,  laboratory  aids  in,  184 
Headache  powders,  composition  of,  87 
Heart,  examination  of,  165 

failure  cells  in  sputum,  33 
Heat  and  nitric  acid  test,  110 
Hemalum,  use  of,  84 
Hematuria,  119 
Hemoglobin,  59 

estimation  of,  59 

in  urine,  119 

Hermann-Perutz  test,  199 
Hookworm,    152 

Hydrochloric    acid     (see    Acids,    Poi- 
sons, etc.) 

Hydrocyanic  acid,   cautions  when  in- 
haling,  181 

detection  of,  91 

properties  of,  187 
Hydrogen  dioxid,  190 
Hydrophobia,  laboratory  aids  in,   183 
Hyoscin,  detection  of,  90 


Imbedding  of  tissues,  83 
Indican,  significance  of,  123,  195 

detection  of,  196 

Indications  for  laboratory  aids,  182 
Indicators,    15 

in  gastric  analysis,  75 

in   urinalysis,    109 
Indolacetic  acid,   197 
Infant  feeding,  136 
Infant's   stools,   154 
Inflammable  chemicals,   181 
Influenza  bacillus,  50 
Influenza,   laboratory  aids  in,   183 
Ink    methods    to    find    the    treponema 

pallidum,    171 
Inoculations,  38 

stabs  and  streaks,  38 
Internal  myiasis,  182 
Internal  psorospermiasis,  182 
Intestinal  obstruction,  laboratory  aids 

in,  184 

Intestines,  examination  of,  167 
lodin  test  for  malingering,  124 
lodoform  as  a  deodorizer,  24 

properties  of,   190 
lodophilia,  58,  68 

J 

Jaundice,  laboratory  aids   in,   184 

K 

Karyokinesis  in  blood  cells,  56 
Karyorrhexis  in  blood  cells,  56 


Kidneys,  examination  of,  166 
Klebs-Loffler  bacillus,  45 
Knife  for  microtome,  8>0 
Knock-out  drops,  87 


Laboratory  aids  in  disease,  182 

arrangement  of  the  physician's,  23 

bacteriological,  21 

book*,  24 

equipment,  13 

experts,  25 

for  milk  analysis,  129 

prophylaxis,  177 

tables,  21,  23 
Lactic  acid,  test  for,  75 
Lead  acetate,  91 

in  water,  140 
Leucorrhea,  98,  99 
Leukemia,  58 
Leukocytes,  57 

counting  of,  62 

in  exudates,  97 

in  sputum,  32 

in  urine,  117 
Leukocytosis,  58 
Leukopenia,  58 
Liniments,  composition  of,  87 
Litmus  test  in  water,  146 
Liver,  examination  of,  167 
Lobar  pneumonia,  laboratory  aids  in, 

183 

Loffler's  methylene  blue,  45,  48 
Lumbar  puncture,  94 
Lungs,  examination  of,  166 
Lye.  composition  of,  88 
Lymphatic  leukemia,  58 
Lymphocytosis,  97 

M 

Macroblast,  56 

Malaria,  laboratory  aids  in,  182 

parasite  of,  67 

Male  genitalia,  examination  of,  167 
Marsh  apparatus,  85 
Marx's  fluid,  68 
Matches,  composition  of,  88 
Measles,  laboratory  aids  in,  182 
Megaloblast,  50 
Megalocyte.  50 

Meninges,  examination  of,  161 
Merctirialism,  99 
Mercury  snlts.  detection  of,  91 
Ifethjrlene  blue,  use  of,  44 
Microblast,  56 
Microcyte.  56 
Microscope,  14 

choice  of  instrument,  14 


206 


v  DKX. 


Microscope — cont'd. 

condenser,  18 

focusing,  20 

illumination,  18 

iris  diaphragm,  18 

lenses,  20 

mirror,  18 

objective,  20 

ocular,  19 
Microscopic  hysteria,  20 

technic,  18 
Microtome,  79 

knife,  80 
Milk,  125 

advantages  of  modified,  128 

amount  daily,  132 

analysis  of,  133 

apparatus  for  analysis  of,  125 

borax  in,  135 

color  of,  133 

cream,  134 

fat  estimation  of,  135 

formaldehyde  in,  134 

formulas,  136 

maternal,  137 

microscopy  of,  134 

modifications  of,  136 

odor  of,  134 

prescription  for,  129 

proprietary  substitutes,  127 

reaction  of,  134 

sample  of,  131 

sodium  bicarbonate  in,  135 

specific  gravity  of,  134 

tampering  with,  131 
Morphin,  detection  of,  92 
Mucus,  27 

in  gastric  contents,  74 

in  sputum,  27 

in  stools,  154 

in  urine,  108 

versus  pus,  27 

Mumps,  laboratory  aids  in,  183 
Muscular  rheumatism,  laboratory  aids 

in,   184 
Myelogenous  leukemia,  58 

N 

Necropsy   (see  Autopsy) 
Negri  bodies  of  hydrophobia,  183 
Neoplasms,  laboratory  aids  in.  1S."> 
Nessler's  reagent.  90 

composition  of.   190 
Neutral  red   in  water  analysis,   146 
New  born,  autopsy  of,   169 
Normoblast,  56 

O 

Obesity,  laboratory  aids  in,   184 
Occult*  blood,  test  "for,  140 


Oil  of  spearmint,  190 

Opium,  detection  of,  92 

Oppler-Boas  bacillus.  7"> 

Order  of  procedure  in  autopsy,  159 

Ova  of  worms.  153 

Oxalates  in  urine,  121 

Oxaluria  dolorosa,  121 


Pancreas,  examination  of,  167 
Pancreatic  test.  114 
Paradoxical  stain.  .~>7 
Paraffin  imbedding,  84 
Parasites,  151 

in  blood,  67 

in  feces,  151 

in  urine,  121 

in  water,  141 
Parasitic     skin     diseases,     laboratory 

aids  in,   185 

Paris  green,  composition  of,  88 
Peritonitis,  laboratory  aids  in,   184 
Phenol,  detection  of,  90 
Phcnolphthalein,   15 

in  stomach  analysis,  75 

in  urinalysis,   109 
Phosphates*  110 

crystals  in  urine,  121 
Phosphorus,  detection  of,  92 
Pinworms  in  feces,  150 
Pipettes,  16 

for  blood  counting.  •">:> 
Plasmodium  in  the  blood,  67 
Plate  cultures  of  bacteria,  41 
Poikilocyte,  56 
Poisons,  85 

abortifacients,  87 

acetanilid,  88,  186 

acids,  88 

alkalies,  88 

alcohol,  88,  187 

ammonia,  88,  187 

antipyrin,   188 

apparatus  for  detection  of,  85 

arsenic,  89,  188 

atropin.  90.  188 

bad  whisky,  87 

bitters.   S7 

bracers.  S7 

enntliaridin.   90 

carbolic  acid.  90.  186 

chloral  hydrate,  90,  188 

cocain.  S7.  90.   IS'.i 

cough  syrups.  87 

drug  cures.  S7 

ergot,  91 

formalin.  91.  189 

headache  powders.  87 

hydrocyanic  acid.  91.   181,   187 


INDEX. 


207 


Poisons  —  cont'd. 

hyoscin,  90 

knock-out  drops,  87 

lead,  91,  140,  190 

liniments,  87 

lye,  88 

matches,  88 

mercury  salts,  91,  190 

morphin,  92,  190 

opium,  92,  190 

paris  green,  88 

phenol,  90 

phosphorus,  92,  190 

rat  poisons,  88 

sex  stimulants,  88 

silver  nitrate,  92,  191 

skin  beautifiers,  88 

sources  of,  87 

strychnin,  92,  191 

sulphonal,  92,  191 

trional,  92 

wood  alcohol,  187 
Polychromatophilia,  57 
Post-mortem  technic,  156 

bacteriological,  157 

brain,  162 

chest,   164 

cord,  '168 

duodenum,  167 

equipment,  156 

female  genitalia,   168 

heart.  165 

in  new  horn.  169 

inspection,    palpation,    and    percus- 
sion, 160 

intestines,  167 

kidneys,  166 

liver,  167 

lungs,  166 

male  genitalia,  167 

mcninges,  161 

microscopic  morbid  anatomy,  157 

orriei   of  procedure,   159 

pancreas.  167 

precautions  in,  156 

prepartions  for..  157 

private   posv-m  >rtem,   156 

prophylaxis  \.\    i70 

special   sense   01  jans,   163 

spleen.   166 
stomadi.    1^7 
trunk. 


uncover 


.     ISfc. 

proper  1'es   of, 


Potassium     •;•!<!  m 

11)1 

chromate.   .  r  -.•  ti.s  of.  191 

as  an  ind;  •>r    143 

hydrate,  pr-  ti-M  of,   191 

Pregnancy,  lal  '  >i-y  aids  in,  185 


Prescriptions  for  modified  milk,  129 
Proprietary  infant  foods,  127 
Proteids  in  milk,  130 

in  urine,  109 
Ptyalism,  99 

Puncture  fluids    (see  Exudates) 
Pus  in  exudates,  97 

in  sputum,  27 

in  urine,  117 

versus  mucus,  27 


R 


Rape,  proof  of,  98 
Rat  poisons,  composition  of,  88 
Reaction  of  gastric  contents,  75 
of  milk,  134 
of  saliva,  99 
of  urine,   109 
of  water,   140 

Reagents,  properties  of,  18*6 
acacia,  '186 
acid,  acetic,  186 

chromic,  186 

hydrochloric,  187 

nitric,  187 

picric,  187 

sulphanilic,  187 

sulphuric,   187 
alcohol,  ethyl,  187 

fusel,  187 

ammonium  hydrate,   187 
azolitmin,  188 
benzidin,  188 
calcium  chlorid,  188 
Canada  balsam,  188 
carbol-xylol,  188 
celloidin,  188 
charcoal,  188 
chloroform,  188 
dimethylamidoazobenzol,  189 
distilled  water,  189 
ether,  189 
ethyl  chlorid,  189 
ferric  chlorid,  189 
formalin,  formaldehyde,  189 
glycerin,  189 
Gunzburg's  reagent,  189 
Haines'  solution,  189 
Hayem's  solution,  189 
hydrogen  dioxid,  190 
iodoform,   190 
Marx's  fluid,  68 
Nessler's  reagent,  190 
oil  of  spearmint,  190 
phenolphthalein,    190 
potassium  bichromate,  191 
chromate.  191 
hydrate,   191 
silver  nitrate,   191 


208 


INDEX. 


Reagents — cont'd. 
sodium  chlorid,  191 
citrate,    191 
nitrite,  liil 
stannous  chlorid,  191 

SHTct    Oil,     191 

turmeric,  191 

urotropin,   191 

zinc,  191 
Red  blood  corpuscles,  56 

artifacts  in,  64 

( l;i>sification  of,  56 

counting  of,  60 

development  of,  53 

in  exudates,  97 

in  feces,  149,   154 

in  sputum,  32 

in  stomach  contents,  73 

in  urine,   113 
Rheumatic   fever,   laboratory  aids  in, 

183 

Rickets,  laboratory  aids  in,  184 
Rubella,  laboratory  aids  in,  183 
Russo  typhoid  test,  102 
Rust,  removal  of,  194 


Saccharimeter,  113 

Sapremia,  laboratory  aids  in,  183 

Sarcines,  75 

significance  of,  76 

Scarlet  fever,  laboratory  aids  in,  182 
Searching  for  germs    (see  Germs) 
Sectioning,  80,  83 
Septicemia,  laboratory  aids  in,  183 
Serum  proteins  in  urine,  109 
Sewage,  141 

Sex  stimulants,  composition  of,  88 
Silver  nitrate,  detection  of,  92 
Skin  beautifiers,  composition  of,  88 
Slides,  cleaning  of,  14 
Smallpox,  laboratory  aids  in,  184 
Smegma    bacillus,    differential    stain, 

123 
Sodium  chlorid,  properties  of,   191 

citrate,  properties  of,  191 
as  a  reagent,  96 

hydrate,  solution  of,  75 
Special  sense  organs,  examination  of, 

163 
Specific  gravity  of  milk,  134 

of  urine,  107 

Spermatozoa,  identification  of,  97 
Spermatorrhea,  diagnosis  of,  98 
Spirochetae,  173 
Spleen,  examination  of,  166 
Spoon  urinalysis,  194 
Sputum,  27 

apparatus  for  examination  of,  27 


Sputum — cont'd. 

color  of,  29 

consistence  of,  27 

difficulties.  :;:; 

elastic  tissue  in,  29 

leukocytes  in,  32 

odor  of,  2!  i 

quantity  of,  27 

red  blood  cells  in,  32 

spreading  of,  31 

staining  of,  31 

tubercle  bacillus  in,  32 
Squibb's  urea  apparatus,  115 
Stab  method  of  inoculation,  38 
Stains,  15 

carbol-fuchsin,  31 
gentian  violet,  31 
thionin,  81 

eosin,  68,  84,  189 

Gram's,  84 

hemalum,  84,  190 

methylene  blue,  48",  190 

neutral  red,  190 

on  fingers,  194 

simple,  43 

thionin,  81,  191 

Wright's,  65,   192 

Stannous  chlorid,  properties  of,   191 
Staphylococcus,  48 
Starch  grains  in  gastric  analysis,  74 

in  malingering  test,  124 
Sterilization,  41 

of  cover  glasses,  42 

of  glassware,  41 

of  hands,  42 

of  media,  41 

of  metalware,  41 

of  tables,  42     . 

of  towels,  42 
Sterilizers,  22,  41 
Stomach  analysis,  71 

apparatus  for,  71 

blood.  73 

chemical,  75 

color,  73 

interpretation  of,  76 

macroscopic  examination,  73 

microscopic  examination,  74 

physical  characteristics,  74 

preparation  for.  71 

sources  of  error  in.  77 

value  and  limitations  of,  77 
Stomach  tube,  use  of,  72 

washing,  technic  of,  71 
Stomatitis,  laboratory  aids  in,  184 
Stool  tests,  148 

ameba  coli,   150 

apparatus  for,  148 

ascaris  lumbricoides,  150 

bacteria,  149 


INDEX. 


209 


Stool  tests — cont'd. 

blood,   149,   154 

color,   149 

consistency,    149 

hookworm,  152 

infant's,   154 

Koch's  bacillus,   150 

mucus,    154 

obtaining  the  specimen,  148 

occult  blood,   149 

odor,    149 

ova,   153 

pinworms,    150 

tapeworms,   151 

value  and  limitations  of,  155 
Streak  method  of  inoculation,  38 
Streptococcus  pyogenes,  47 
Strychnin,  detection  of,  92 
Sugar  of  milk,   130 

in  urine,  113 

Sulphonal,  detection  of,  92 
Sulphosalicylic   acid,    198 
Sweet  oil  as  a  reagent,  90 

properties  of,   191 
Syphilis,  laboratory  aids  in,  183 

butyric  acid  test  for,  99 

Perutz  test  for,   199 


Table  microtome,   79 

Tallqvist  hemoglobin  chart,  59 

Tapeworms   in   feces,   151 

Tenia   in  feces,   151 

Test  meals   in   gastric   analysis,    71 

Tetanus,   laboratory  aids  in,   183 

Thrush    fungus,    49 

Tissues,  examination  of,  78 

apparatus,   78,   82 

celloidin,  82 

curettings,  84 

freezer,  80 

imbedding,  83 

microtome,   79 
knife,  80 

paraffin,  84 

sectioning  of,  80,  83 

staining    of,    80 
Tonsils,    diseases    of,    184 
Treponema  examinations,   171 

advantages   of   methods    in,    175 

apparatus  necessary,  171 

criticism  of  methods,   174 

disadvantages  of  methods,  174 

examination  in  dry,  173 
in   wet,    173 

identification,    173 

obtaining   the   specimen,    171 

preparing  the  specimen,    171 

principle  involved,   175 

sources  of  error,  174 


Treponema   examinations — cont'd 
spirochetse    as    confusing    elements, 

173 

Trional,  detection  of,  92 
Triple  phosphates  in  urine,  121 
Trunk,  examination  of,   163 
Tubercle  bacillus,  32 
in  feces,   150 
in  sputum,  32 
•  in  urine,   121,   123 
Tuberculosis,  laboratory  aids  in,  183 
Turmeric  as  a  reagent,  135 

properties   of,    191 
Typhoid    bacillus,    48 

identification   in   drinking   water, 

141 

fever,   laboratory   aids   in,    182 
tests,    100 

U 

Urate  of  ammonium,  120 
Urea  in  urine,  115 
Uric  acid  in  urine,  115,  120 
Urinary   sediments,    116 

blood   cells,    119 

calcium    carbonate,    121 

calcium  oxalate,   120 

casts,   117 

classification    of,    120 

collection  of,   116 

cylindroids,    118 

epithelial   cells,    120 

leukocytes,   117 

phosphates,  121 

pus  cells,   117 

triple  phosphates,  121 

urates,    120 

uric   acid,    120 

spermatozoa,   98 
Urine,   107 

albumin   in,    109 

ammoniacal  fermentation  of,  121 

amount   of,    107 

bacteria  in,    123 

betaoxybutyric  acid  in,  116 

bilirubin   in,    113 

blood  in,  113 

casts  in,   117 

characteristics   of  normal,   107 

chlorides   in,   115 

choice  of  tests,    110 

clap   threads   in,    117 

color  of,    108 

crystals  in,  120 

cylindroids  in,   118 

diacetic  acid  in,   116 

epithelium  in,   120 

filtration  of,    110 

foreign  matter  in,   118,   121 

glucose   in,    112 

hemoglobin  in,  119 


210 


INDEX. 


Urine — cont'd. 

leukocytes  in,   117 

odor   of,    108 

oxalates  in,   120,  200 

parasites  in,  121 

phosphates  in,  110,  121 

pus  in,   117 

reaction  of,  109 

specific  gravity  of,   107 

spermatozoa  in,  98 

tampering  with,    124 

transparency  of,   108 

turbidity  of,  108 

urobilinogen  in,  114 

worms   in,    121 
Urine  of  acid  cystitis,  122 

alkaline  cystitis,   122 

autointoxication,   123 

diabetes,   123 

foudroyant  cystitis,  122 

interstitial  nephritis,   123  • 

oxaluria  dolorosa,  121 

parenchymatous  nephritis,   122 

pyelitis,  122 

renal   calculus,    122 

specific  urethritis,   122 

uremia,    122 

vesicle  calculus,  122 
Urobilinogen,  in  urine,  114 
Urotropin  as  a  substitute  for  gas,  17 

properties  of,  191 

Uterine   diseases,   laboratory   aids   in, 
185 


Vaccinia,  laboratory  aids  in,  182 
Varicella,  laboratory  aids  in,   182 
Verrucse   necrogenicse,    179 

W 

Water  analysis,  138 
algae,   141 


Water — cont'd. 

animal  parasites,  141 

apparatus,   144,  146 

bacteria,   142 

bowel  bacilli,  145 

colon  bacillus,    1  l.~> 

commercial  waters,   139 

comparative  chlorin,   143 

dead  animals.  141 

fluorescence  test,  146 

lead,  140 

limitations  of,  145 

litmus  test  in,   146 

odor/ 140 

poisons,  139 

reaction,   140 

scientific  versus  practical,  138* 

M-wagp,  142 

sources  of  error  in,  144 

typhoid  bacillus,   141 

value  of,  145 
Water,  changing  of,  139 

running,  for  laboratory,  18 
Weights  and  measures,   1!>2 

in  post-mortem  work,  158 
Whooping-cough,    laboratory    aids   in, 

183 

Widal  reaction  of  blood,  103 
Worms  in  feces,   150 
Wright's  blood  stain,  65,  192 


Yeasts  in  gastric  contents,  75 
Yellow  fever,  laboratory  aids  in,  183 


Zinc,  in  arsenic  test,  85 
in  hemoglobin  test,   120 
properties,  of,  191 


Date  Due 


CAT    NO.   24    161 

•MHNTEO  IN  <!.•.*• 


°°0  499  638 


QY25 
WT21L 
1913 

Williams,  Byron  G.  R. 
Laboratory  methods . . . 


QY25 
WT21L 

1913 

Williams,  Byron  G.  R. 
Laboratory  methods . . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


